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ISSN 1368-2105 (print) ISSN 2045-6174 (online)

Summer 2011

How I use the evidence in dysphagia management

Strategy Total Communication - Now! Community sentences An exploratory study Service delivery Read to succeed Goal negotiation Getting the process right Journal Club Intervention studies

PLUS...heres one I made brief...reader offers ...and My Top Resources to help people with dementia

Reader offers

WIN Photosymbols 4!

Win Regular and Irregular Plurals!

Grow Words publishes a range of practical resources that contain photocopiable games, activities and worksheets that target a range of language and literacy skills.

Photosymbols are photographs of real people and objects mixed with graphics that you can use to make easy-to-read information, whether you want to communicate ideas, emotions or meaning. As well as a USB flashdrive they come in an online library, and you can create your own album and add your own customised photos. Photosymbols 4 adds another 500 pictures to the 3000 strong library from previous versions, with many original pictures remastered. They are intended for use with all age groups and feature a wide range of diverse people. Photosymbols 4 normally costs from 480.00, but you can win a single user licence FREE simply by e-mailing your name and address to Entries must be received by 25 July and the winner will be notified by 1 August 2011. You can find more information about Photosymbols 4 on Grow Words is offering THREE readers of Speech & Language Therapy in Practice a CD containing Regular Plurals & Irregular Plurals. The resources contain step-by-step instructions that make them ideal for home programmes. Multiple opportunities for practice are provided to facilitate mastery of the targets. Each CD is worth approximately 35, but you can enter the draw to win one FREE by emailing with Speechmag Summer Grow Words Offer in the subject line by 25 July. The winners will be notified by 1 August 2011. Grow Words is run by two Australian speech pathologists. Information about all Grow Words resources, including sample pages and how to order, is at

Previous winners

The lucky winners of our fantastic Spring 11 offers are: Tracey Corbett, Susan Bannatyne and Karen Cooke (Grow Words Food Words series CD), Christine Hobden (NDP3 Speech Builder Therapy Software) and Kathleen Johnstone (Independence Through Communication from Black Sheep Press). Congratulations to you all, and thanks to the three companies for their prizes.

Win I CAN Secondary Talk Narrative Resources!

Are you looking for materials to support your work with secondary aged pupils (Key Stages 3-4)? Black Sheep Press is offering THREE copies of the Narrative Resources from I CANs Secondary Talk. Using narrative frameworks can help pupils with poor levels of oral narrative to have more success in written tasks. This pack, developed by Bec Shanks in collaboration with I CAN, explains the importance of narrative and the range of narrative styles required across the secondary curriculum. It includes 17 adaptable templates for recounts and accounts, scripts, persuasive texts and stories. The pack is in colour on CD, with illustrations by Helen Rippon. New narrative icons suited to an older age are included (pictured). To enter this free prize draw, email with Speechmag narrative offer in the subject line by 25 July. The winners will be notified by 1 August 2011. I CAN Secondary Talk Narrative Resources costs 18. It is part of a wide suite of speech and language resources for secondary aged pupils developed as part of I CANs Secondary Talk programme. To find out how Secondary Talk can benefit a school visit secondarytalk. For details of Black Sheep Press Resources, see

Summer 2011 (publication date 31 May 2011) ISSN 1368-2105 (Print) ISSN 2045-6174 (Online)

Summer 11contents
26 COVER STORY: HOW I USE THE EVIDENCE IN DYSPHAGIA MANAGEMENT (1) PREPARED, PROACTIVE AND PREVENTATIVE Shyamani moved post to develop her dysphagia skills, particularly within the acute context. During reflective sessions she felt overwhelmed with the nature of some of the difficulties, particularly with infants. Celia Harding and colleagues demonstrate how an evidence-based problem solving framework can support community and developing specialist therapists to provide appropriate intervention to infants and children with early feeding, eating and drinking difficulties. (2) A QUESTION OF TASTE We now work towards implementing some level of oral intake for all our clients receiving PEG feeds who have shown they want to have this. Hannah Crawford and Julie Bake explain why and how they have moved away from previous practice and introduced oral taster programmes with people with learning disabilities and dysphagia who gain their nutrition via percutaneous endoscopic gastrostomy (PEG).

Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 email: Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor Avril Nicoll, Speech and Language Therapist

Photo of Richard with Julie Bake by

INSIDE FRONT READER OFFERS Fantastic offers for you in the Summer 11 issue! Photosymbols 4; I CAN Secondary Talk narrative and a Grow Words resource set. 4 STRATEGY Parts of Devon are already experiencing a reduction in lengthy waiting lists and times as, following assessment, people and their support worker or carers can be signposted to book into a Total Communication Now slot to support the therapeutic intervention process. Charlotte Smith and Andrea Arnold look back on an evolving project to help adults with learning disability and all those around them communicate more effectively. 7 REVIEWS Software, oro-motor, neurology, dyslexia, teenagers, narrative, generalisation, intensive interaction, Aspergers syndrome, human development, ethics, memory, AAC, research, evidence to practice, CHARGE syndrome. 10 GOAL NEGOTIATION (2) Consider this a flexible framework to be adapted in accordance with your work context, not something to be applied rigidly and unquestioningly. In the second of our series of four articles on goal negotiation, Sam Simpson and Cathy Sparkes take us from the first meeting through to preparation for discharge.

13 HERES ONE I MADE EARLIER If we can record a story in a concrete provides a lovely way to celebrate the childs achievement. It creates a permanent record to take home, as well as offering opportunities for repeated output through re-telling the story to family and friends. Cynthia Pelman encourages her clients to make their own books. 14 ASSESSMENT Our findings need to be confirmed in larger-scale studies before making any firm recommendations for practice. However...they have implications for the way offenders are identified as having problems and communicated with as they progress through the criminal justice system. Rachel Iredale, Beth Parow and Harriet Pierpoint undertake an exploratory study of speech, language and communication difficulties among offenders completing community sentences. 17 IN BRIEF Caroline Newton and Carolyn Bruce put the accent on aphasia. 17 EDITORS CHOICE 18 JOURNAL CLUB (4) INTERVENTION STUDIES The gold standard design for an intervention study is the randomised controlled trial (RCT). The framework in this article can also be used for other types of intervention study, such as exploratory, preliminary or pilot-study designs.

Jennifer Reids series takes the mystery out of critically appraising different types of journal articles. 22 SERVICE DELIVERY The most noticeable changes from the project were in the results for the three identified practitioners. They each showed considerable improvement in interaction, dialogic reading strategies and activities to extend the stories. Kate Wright on the impact of a collaborative project with a childrens centre and library service in an area of deprivation. 25 BOUNDARY ISSUES (5) A full-time member of your team has been evolving a new role. There is no new money, and no benefit to the teams usual clients. Where before you had the flexibility to adapt and innovate, you are now struggling to provide them with an evidence based service. Linda Armstrong responds to the fifth scenario of our ethics series. 34 MY TOP RESOURCES Some of us have special arrangements with individual care homes who allow us to be involved in handover or inservice programmes, while others have innovative ways to get people to attend the training (such as just turning up and starting a workshop in the lounge!) Kate Balzer shares ideas for working with people with dementia that came out of a therapy swapshop.

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2011 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.

Speech & Language Therapy in Practice can be found on EBSCOhost research databases.



Expertise of parents

Stammering Support Centre

Consultant speech and language therapist Dr Trudy Stewart has achieved her career dream with the opening of the new Stammering Support Centre in Leeds. Following a feasibility study commissioned by Ed Balls, then in the Department of Children Schools and Families, the strategic health authority agreed that all the primary care trusts in the Yorkshire & Humber region will contribute to the Centre for two years. This will fund child and adult referrals to the Centre and / or training for speech and language therapists. The opening of the Centre is the first step in delivering equitable and accessible specialist services for the region. Children, families and adults from other parts of the country can also access the service, once funding has been agreed with their local primary care trust. The Reginald Centre, which houses the Stammering Support Centre, is a shared community resource that has excellent modern facilities for individual and group therapy as well as meeting rooms and light and airy waiting areas. Trudy hopes that the Centre will make a significant difference to clients and speech and language therapists, and will prove to be a model that can be adopted by other regions.

If government proposals to give GPs in England control over commissioning go ahead, Contact a Family wants parents with disabled children to have an input. They charity is basing its call on the results of an online survey of 1080 parents, which found that only 24 per cent have any GP involvement in the care of their childs condition. Although 87 per cent visit the GP about their childs general health issues, the quality of care is inconsistent, and only 27 per cent say that their GP offers them support in their role as a carer. Sixty two per cent of the responding families also want improved joint working of GPs with other professionals. Chief Executive Srabani Sen says How are GPs going to plan for disabled children, who are often highly dependent on health services, when the majority have no involvement in their care? We would like to see assurances that parents with disabled children will be involved in GP commissioning consortia so they can input their expertise. For the policy briefing Putting families with disabled children at the heart of NHS reforms, tel. 020 7608 8741.

Multilingual Toolkit forms part of New RDLS

The 4th edition of a test first introduced to the profession in 1977 includes a Multilingual Toolkit to assist speech and language therapists in providing a more accessible service for children from bilingual or multilingual backgrounds. The New Reynell Developmental Language Scales have been revised based on recent research in the field of child language and feedback from users of the 3rd edition. Authors Susan Edwards, Carolyn Letts and Indra Sinka have reduced the amount of stimulus material, and standardised the latest version on 1200 children in the UK aged from 2 to 7;5 years. The Multilingual Toolkit has been produced to help clinicians adapt the concepts and material to situations where there is linguistic and cultural diversity. The NRDLS costs 499 plus VAT for a Complete Set, comprising the test manual, The Multilingual Toolkit and record forms.

Standards for networking

The Health Professions Council says it rarely needs to take action over a registrants use of social networking sites, and would only do so if this raised concerns about their fitness to practise. The regulator says it has no concerns about therapists and students enjoying social networking sites as long as this use is consistent with its Standards of conduct, performance and ethics. This means acting in the best interests of and respecting the confidentiality of service users, keeping high standards of personal conduct and behaving with honesty and integrity, and making sure any behaviour does not damage the publics confidence in you or in the profession. Registrants should also be aware that this could include sharing information about a colleagues personal life, health or circumstances, or posting offensive views or sexually explicit material. Source: HPC in Focus Issue 34 April 2011

Speak About Aphasia

Speakability is encouraging speech and language therapists and people with aphasia to get involved in the June 2011 Speak About Aphasia month. The charity is directing its awareness-raising efforts at health professionals such as GPs, dentists and opticians, who regularly work with people with aphasia but who perhaps do not recognise Aphasia as the communication disability that it is. It suggests that people can help by sending the campaign postcard to their local GP surgeries, health centres, dentists, opticians and hospitals, and by holding events. Speakability offers practical support and information to people with aphasia and their carers through a free Helpline (080 8808 9572), a range of publications and a national network of self-help groups.

Good practice awards

Sample service

Sl Drinks, who produce easy to prepare hot and cold thickened drink bases, have introduced a free patient sample service. The company hopes this will be useful for clients who are unsure about using the drinks. To organise the free samples, email with the consistency required (1, 2 or 3) and the postal address. The samples can come to you, or directly to the clients home.

The Hello campaign for the National Year of Communication is going to 'Shine a Light' on good practice for children and young people's communication with an extensive awards scheme. The Royal College of Speech & Language Therapists is sponsoring Team of the Year for speech and language therapists, and there are other categories for outstanding achievement, communication friendly establishments, different teams, communication strategy, commissing and employee support. You might also want to have a think about potential candidates for the Hello Young Person of the Year Award, open to children and young people up to 19 years with speech, language and communication needs. Entries close on 15 July 2011.



Find out what living with aphasia is like via the Connect blog. NHS Evidence has re-launched with a broader range of guidelines and information. This video gives you a quick guide: FirstStop Advice offers independent advice and information for older people, their families and carers about housing and care options in later life. The Database of Research in Stroke (DORIS) is in development, and you can register to be updated as it goes live. WriteOnline ToGo from Crick Software and dyslexia specialist iansyst is a complete writing solution for students who find writing difficult, and includes integrated speech, word prediction, word banks, writing frames and a visual mind mapping tool. Prices start from 449. Talk To Your Baby is asking professionals to point parents and carers to a new website which emphasises the positive role they can play in helping their baby to develop communication skills. I CAN has published a guide about what specific language impairment means, looks, feels and sounds like, and how to get help. The SLI Handbook is 2.50 + p&p. Latest resources from Black Sheep Press include the Informal Social Communication Assessment for children aged 5-11 years, the second edition of Why/Becasuse, and Key Stage 1 Narrative with Welsh text picture pages. The first two steps in the See and Learn Speech program to help children with Down syndrome (6 months - 7 years) improve speech discrimination skills and develop clearer speech production will be available shortly in the UK. The developer of a website of hypnotherapists in the UK says all those listed have either submitted copies of qualifications and insurance cover, or are registered with a professional body with recognised codes of ethics and practice. Independent speech and language therapist Libby Hill is inviting international contributions and subscriptions to her online magazine S&L World Bulletin. ACT suggests that professionals who work infrequently with life-limited and life-threatened children may find its Childrens Palliative Care Handbook for GPs helpful. It includes sections on breaking significant news and managing denial and collusion. The Fragile X Society has produced an easy read guide to the condition, aimed at parents with learning disabilities. It has been sent to all genetic centres, but you can download it at:


Comment: Celebrating achievement

rudy Stewart (News, p.2) is celebrating the opening of the new Stammering Support Centre in Leeds. Her career dream finally took shape when the right person (Ed Balls) was in the right place (Department of Children Schools and Families) at the right time to get the process started. The centres establishment is the key step in a coordinated hub and spoke strategy to deliver evidence based therapy to people of all ages across the region. Charlotte Smith and Andrea Arnold (p.4) say, At a time when there is sadness and loss to face within public sector services and our profession, as well as issues to take a stand on, it is even more important to reflect on our successes. Like Trudy, they are celebrating the evolution of an original vision to county-wide reality although on many occasions the idea seemed no more than a paper-based aspiration. No doubt there will be further challenges ahead, but their solution focused, collaborative approach will continue to bring positive results. Kate Wright (p.22) and her team also went about their project in a logical way. Having recognised a need, they gathered information from the literature to help structure implementation, and appeared to achieve their greatest impact through targeted training. Celia Harding and colleagues (p.26) incorporated findings from different types of research, including parental views, into a problem-solving framework to assist therapists to grow in confidence and competence in a developing area. Hannah Crawford and Julie Bake (p.30) use a framework for evidence based practice to challenge and change previous approaches, giving due weight to the wishes of clients because they dont present like text book cases, and the answers or the most appropriate treatment routes are not always the most obvious, nor necessarily the ones we would choose for ourselves. One area of practice that has evolved considerably in recent years is dementia care. Kate Balzers top resources (p.34) show how more coordination, evidence and strategic thinking are being brought to the task. As Linda Armstrong (p.25) says, our predecessors would hardly recognise much of our work now. Linda has wise words of warning about the impact of new roles on our existing clients when they are not accompanied by new resources or a strategic cut in current services. Rachel Iredale, Beth Parow and Harriet Pierpoint (p.14), who are investigating apparent unmet need for speech and language therapy among offenders serving community sentences, also recognise this as a danger. While research evidence, client preference and the therapists expertise are seen as the three components of evidence based practice, Jennifer Reid (p.18) observes that constraints of the local context are often added as a fourth. Sam Simpson and Cathy Sparkes (p.10) helpfully show how their goal negotiation framework can be used flexibly across different settings. Cynthia Pelman (p.13) finds that bookmaking provides a lovely way to celebrate her clients achievements - and this magazine is a lovely way to celebrate and share the achievements of resilient, enthusiastic and thoughtful therapists.



Total Communication Charlotte Smith and Andrea Arnold look back on how the Total Communication Now project has evolved from an original vision to a county-wide initiative that continues to help adults with learning disability and all those around them discover new ways to communicate more effectively.

e are writing this on behalf of a wider group of therapists who work with adults with learning disability. At a time when there is sadness and loss to face within public sector services and our profession, as well as issues to take a stand on, it is even more important to reflect on our successes. We wanted to share an innovative project that has enabled us to develop partnership working and meet communication needs more effectively at a community level. It has been an uplifting experience for all involved, and we hope it will inspire you to be bold in your ambitions. Total Communication Now creates opportunities in local places in Devon for people with learning disability, support workers, other professionals and family carers to get ideas and help in making meaningful visual aids to support whatever they need to communicate about. In addition, organisations can get help and advice in making their face-to-face communication, signage and information easier to understand, thereby becoming more inclusive. There has been a Total Communication Strategy in Devon for many years, thanks originally to the generous support and inspiration of Jane Jones and her colleagues in the Somerset adult learning disability speech and language therapy service. Total communication training has been provided by speech and language therapists and cotrainers as part of this. Implementation of the county-wide strategy has fluctuated depending on resource levels, and at times it has felt like a paper-based aspiration. However, two years ago, we were successful in getting Total Communication written into the Devon Learning Disability Health and Social Care Partnership Business Plan under the Freedom from discrimination and harassment outcome: Tackling inequalities remains a fundamental part of everyones role working with people learning disabilities, not least of which are the inequalities inherent in our own practice and systems. As noted in Valuing People Now (2009), if services develop communication and accessibility for people with more complex needs, they are probably getting it right for most people.

As a result, we were able to put the Total Communication Now project proposal forward and secure funding from the Learning Disability Development Fund. This was a significant breakthrough.

Funded time

In the first year the funding paid for 14 mobile kits. These include a touchscreen laptop with relevant software, a printer, laminator, camera and small hand-held video-cameras which can be loaned out. There is input from speech and language therapists employed by three different Trusts, and vitally important time was funded for trained support workers to provide local learning opportunities for one day every two weeks. The kits are based within a day service building for use there and in other venues across ten towns and their surrounding areas. We ran thirty five workshops and roadshow events to promote the project and demonstrate how Total Communication can improve the quality of everyday interactions. Solution focused ideas are central to

the principles and processes of the Total Communication Now initiative, focusing on what works rather than becoming bogged down in problem-based thinking (Burns, 2005; George et al., 2006; Smith, 2006). The outcomes for individuals are determined by: what communication change the person and / or their supporter wishes for or needs building shared language through visual as well as verbal forms based on what works working together in short bursts, at the persons pace being based in the now and / or what next? in do-able amounts and observable ways enabling maximum involvement of individuals whilst motivating all concerned through noticing what works well. In addition, we have used solution focused approaches to agenda planning within the sixmonthly Devon-wide Total Communication Now staff network meetings. This has enabled us to focus on what we are pleased to notice has worked and to appreciate the different creative solutions and outcomes




opportunities promoted by the Total Communication Now initiative. Here are a few examples of types of outcomes individuals have gained: 1. More people have materials for using with Talking Mats. One person was enabled to make their own decision about a cataract operation; one person chose where to live; one woman was able to communicate she wished to end a relationship, relieving her worry and anxiety. 2. A mother got ideas and symbol pictures to use with her autistic son in letters to each other while he is an in-patient in a mental health unit.

Solution focused ideas are central to the principles and processes...focusing on what works rather than becoming bogged down in problem-based thinking

that have evolved within each area of Devon despite and due to different levels of service capacity and strengths. It has helped us pool and exchange resources, expertise and resourcefulness whilst being employed by different organisations. As a result, there is a buzz at these network meetings and we come away feeling supported, inspired and resilient. Participatory Appraisal, involving service users in planning and evaluation from their point of view, has also been integral to the project, as well as customer feedback forms. For example, 55 people turned up at one of our events and we produced a celebratory slide-show as a participatory activity within the day from the photos taken of the examples people had brought along to show and share.

Good practice

At the end of year one we carried out an evaluation across Devon. We gathered examples of individual and joint good practice which evidenced improved communication

3. A young woman with learning disability for whom English is a second language made a photo-story to aid her transition to a new day service. 4. An autistic man with epilepsy and his keyworker have made a short DVD to show other staff how to communicate with him to enable him to get ready to go out. 5. A woman made a photo-book about her dad after he died, which is helping to support her through her bereavement. In Mid Devon, Total Communication Now has supported people with learning disability in making an awareness raising film about everyday communication breakdown. This film had a special showing at a cinema attended by local councillors. Community services have also gained. For example, in North Devon, the project is helping police to improve communication with victims about hate crime. In South Devon, partnership working is flourishing in the local leisure centre in Newton Abbot. This initiative was inspired by the excellent practice and evidence shared

by colleagues in Victoria, Australia (www. Historic links already existed between adult learning disability services and the leisure centre, as staff used to provide gym sessions at the local day centre. The staff were however keen to move away from this style of working, and were open to ideas for increasing inclusion opportunities within the leisure centre itself. After consultations with the staff team, local groups, and people with learning disabilities who use the leisure centre, we developed a set of visual communication aids. We made a communication board (an A3 colour photographic and symbolic chart) and sited it on the reception desk. It aims to support people to communicate effectively, encouraging positive social interaction and independence throughout the leisure centre. A set of flashcards (of individual photos/symbols) is also available at the reception desk, gym and swimming pool areas. As well as being used to ask specific questions about those activities, they are useful for people who find the large board too complicated. We provided training to a core group of leisure centre staff around using total communication with people with learning disabilities, and particularly about giving people the time and space to use the resources successfully. Information about the new communication board was sent out to carer groups, residential and supported living organisations as well as being promoted in learning disability service publications. The communication board was piloted for a year. An evaluation process involving service users resulted in minor adaptations to the visual display. Feedback was positive, not only from leisure centre staff themselves, but also from a range of individuals and organisations using the centre. Interestingly the leisure centre has found that the communication board has also been useful for others with communication difficulties, including people for whom English is a second language. What has been particularly pleasing is the real interest from other local leisure centres and service providers in making their own resources. As a result, a communication board is now used in three other leisure centres and is beginning to be introduced within library and other District Council services. Overall, Total Communication Now has had a positive impact on the adult learning disability speech and language therapy service delivery, supporting every level of the tiered model described in the RCSLT ALD



Figure 1 How Total Communication Now supports the tiered model of service delivery (RCSLT, 2010) Speech and language therapist uses time with the individual and supporters for assessment, eg. checking visual aids are meaningful The individual referred and / or supporter can book in to: get help in making visual aids to support identified strategies modify existing visual aids to make them more effective learn skills to enable them to update visual aids to keep them relevant in the future come along to show and share good practice workshops

Tier 4 Specialist interventions Specialist interventions to address communication and eating and drinking needs in all environments

Tier 3 Capability in specialist learning disabilities services Interventions which contribute to the creation and maintenance of capable specialist learning disability services

Support staff can get help via Total Communication Now sessions with implementing actions into practice following training, eg. Talking Mat materials, photo menus; producing easier read documents Sharing top copy examples via website Support and training with producing easier to read or multimedia information Support with making materials to support choice-making, decisions and consent Support and training with producing easier to read info, eg. leaflets, standard letters Communication board

Tier 2 Capability in mainstream Interventions to enable the development of capable mainstream services to address communication and eating and drinking needs of people with learning disabilities

Tier 1 Capability in the community Interventions to promote health, well being and inclusion of people with learning disabilities at a general population level

Position Paper (2010, figure 1). Speech and language therapy teams from three different Trusts provide the adult learning disability service across Devon, and all have benefited from this collaborative project. Parts of Devon are already experiencing a reduction in lengthy waiting lists and times as, following assessment, people and their support worker or carers can be signposted to book into a Total Communication Now slot to support the therapeutic intervention process. This initiative is also beginning to offer a preventative element to service delivery by building on the capability in the community and universal services to communicate more effectively and inclusively. We are exploring possibilities for providing this service within library premises and / or services. It is potentially a way to develop further integration with adult speech and language therapy services, with adults with learning disability leading the way in helping to bridge the gap experienced by many people with SLTP communication disability. Charlotte Smith (email charlotte.smith@ is the Professional Lead in speech and language therapy for adults with learning disability in South Devon Locality and Torbay, and the Devon Health and Social Care Learning Disability Partnership Lead for Total Communication. Andrea Arnold (email andrea. is a speech and language therapist with adults with learning disability. Both are employed by South Devon Healthcare Foundation Trust.

Smith, I. (2006) Ideas for Solution Based Working with People who Have Intellectual Disabilities, Solution News 2(2), pp.21-25.



Thanks to everyone else involved in inspiring and making the Total Communication Now project work so well, in particular: South Devon Ian Weller, Dr. Cath Valentine, Gail Rochelle, Lisa Green, Sue Cooke, Helen Buswell (Occupational Therapist) North Devon Anne Kershaw, Lucy Holding, Laura Wignall, Hazel McDonald, Hailey Graham, Colin Cornell, Laura Snead Exeter, East & Mid Devon Sue Brain, Adela Lewis, Lynne Walker, Charmaine Simpson, Lesley Baker, Vicky Hooper.

Participatory Appraisal, see Talking Mats, see


Burns, K. (2005) Focus on Solutions: A Health Professionals Guide. London: Whurr. Department of Health (2009) Valuing People Now: a new three year strategy for people with a learning disability. London: Crown copyright. George, E., Iveson, C., & Ratner, H. (2006) Problem to Solution. Brief Therapy with individuals and Families. London: BT Press. RCSLT (2010) Position Paper ALD. London: Royal College of Speech & Language Therapists.

To comment on the impact this article has had on you, see guidance for Speech & Language Therapy in Practices Critical Friends at www.



REVIVO $125 (USD) Download from As technology becomes more accessible, our in-depth reviews help you decide whats hot and whats not... appeal. Unaware of evidence against oromotor work (Lof, 2009; Powell, 2009), Hopper advises that children do 19 exercises five minutes daily, 2-3 times each, promising facial muscles will be strengthened (they wont) and speech development helped (definitely not). But heres the plan: paste a note about the futility of NS-OMEs (nonspeech oral motor exercises) over the assertions on page one and a fun picture on the back cover to conceal guarantees of facial strength and dexterity and enjoy! Now, wheres that 2-year-old?
References Lof, G. L. (2009). The nonspeech-oral motor exercise phenomenon in speech pathology practice. In C. Bowen, Childrens speech sound disorders. Oxford: WileyBlackwell, pp. 181-184. Powell, T. W. (2009) Non-speech oral motor exercises: An ethical challenge, in C. Bowen, Childrens speech sound disorders. Oxford: Wiley-Blackwell, pp. 199-202.

Does not usefully transfer

This software provides a picture plus written word, sentence or letter along with an auditory model for imitation. Patients record their production using the Revivo Talk Recorder. They can then listen, judge for accuracy and record again if they think they can do better. Some of the items are supported by a video of the mouth movements accompanying the auditory stimulus. Revivo is intended for use in aphasia rehabilitation, but imitation is not a frequently used method in our therapy repertoire. We felt the method was more suited to people with post lexical or motor speech difficulties, and tried it out with three different people (two with dysarthria and one with aphasia). Our review is based on their comments and our views. The software looks home made and the pictures along with the labels (using uncommon words) dont help illustrate what the exercises are. The buttons on the Talk Recorder are small and have text labels but no pictures or colours. We found the exercises slow to load and the video feature worked erratically. The vocabulary selection is unusual (Caesar, xylophone, guts) and there is no logical organisation to the items. There are some spelling errors in the labels. The speech model is hard to listen to and slightly distorted due to vowel lengthening. This set of exercises may have suited the needs and interests of an individual, but does not usefully transfer to others. On a positive note the Talk Recorder is a nice feature and easier to use than the standard Windows recorder. This could be used creatively to good effect by therapists with their own stimuli. Amy Hanschell and Laorag Hunter are speech and language therapists at the Centre for Brain Injury Rehabilitation in Dundee.

brain training, learning styles, extra time and communicating with a SENCO (Special Educational Needs Coordinator). Each chapter contains questions and explanations to help a pupil understand their needs and convey these to others. The colourful cover entices a reader to explore the contents. The ideas can be used selectively and adapted as required. The language would need to be simplified for some pupils. This is a practical and reasonably priced resource for professionals helping to oversee the needs of dyslexic pupils. Alison Maddocks is a specialist speech and language therapist working in secondary schools for Surrey Community Health.


Caroline Bowen PhD, CPSP is an Australian speech-language pathologist,

The Bristol Project DVD 5 teenage boys with communication difficulties Speech and Language Therapy Research Unit 8 contribution requested


Challenges perspectives

Brain Based Communication Disorders Leonard L. LaPointe, Bruce E. Murdoch & Julie A.G. Stierwalt Plural ISBN 978-1-59756-194-5 62.00

Whats not hows

This is a good text and reference book for students on neurology. It is inclusive, it covers lots of conditions - both adult and paediatric and it doesnt leave you with only the basics. However, it is concerned with the whats but not the hows. There are only a few therapy suggestions, there is little reference to recent research and the writing style is too familiar at times, too jokey. It might be good to have around as a memory jogger to stimulate thought and discussion. It provides a lot of information on a wide ranging topic all in one book, but is primarily for students or therapists new to neurology. Mel Barnes is a speech and language therapist in neuro-rehabilitation in Surrey.



Mouth and Tongue Lets Have Some Fun! Karina Hopper, illus. Lisa MacDonald Jessica Kingsley ISBN 978-1-84905-161-3 4.99

So, Ive got what? Understanding what specific learning difficulties mean to you. Dr Hannah Mortimer QEd ISBN 978 1 898873 65 5 6.00

Issues to talk through

Futile but fun

When speech and language therapists recommended mouth exercises for Karina Hoppers children, she and Lisa MacDonald produced an engaging resource with toddler-

This short book by an educational psychologist provides a series of issues to talk through with dyslexic pupils aged 7 to 14. The introduction is followed by eight chapters exploring: the meaning of dyslexia, assessment, ways to help oneself or be helped, coloured overlays,

This 20-minute film explores the question What is it like to be a teenager with a speech and language difficulty? These five teenage boys take control of the film to show the world who they are. It gives an insight into each teenagers strengths and achievements through a range of different mediums, including visuals (photographs, objects, pictures) and narrative (interviews, video-diaries, cartoon animations). However, the teenagers communication difficulties are evident throughout, for example literal understanding, need for routine, struggle to engage in conversation, own agenda, obsessive interests. When the boys are asked about their communication difficulties, they struggle to express and explain themselves and often dont recognise their own social limitations. I found it very insightful and thoughtprovoking, and feel it could be a useful tool within training sessions for other professionals such as teachers, teaching assistants and educational psychologists. It would also be a good teaching tool for students. The production is very abstract, arty and musical, which initially can be difficult to view, but further helps to symbolise the disorganised, chaotic and realistic nature of living with a communication difficulty. The films biggest appeal is that it challenges our views and perspectives. It raises questions about the lack of visibility of communication difficulties and societys expectations around communication. In a climate where our understanding of teenagers with speech, language and communication needs is still very much evolving, this DVD makes a significant contribution. Sarah Mallinson is a specialist speech and language therapist in Manchester with pupils in mainstream primary and secondary schools with speech, language and communication needs.



The Big Book of Storysharing Nicola Grove SENJIT, Institute of Education, Univ. of London ISBN 978-0-85473-898-4 25.00

Celebrates dialogue

This well-priced, practical and easy to read book has inspired me with confidence in my efforts to get narrative into the classroom! There is enough theory to support the case for fun, social interactions based on real life experiences, without being off-putting for parents, carers or teaching staff. Its full explanations of how to share a story can help structure targets and interventions delivered directly by the speech and language therapist or by parents or carers and teaching staff. Developmental levels are given along with strategies for implementation. There are plenty of examples, for children and young adults of all abilities. All rounded off with usable templates for recording stories and assessing and monitoring skills. Great to have a resource that celebrates children using their skills to engage in dialogue. Fiona Soutar is a speech and language therapist working with children with severe, profound and complex learning disabilities at St. Elizabeths School, Herts.

Although it is not easy to read, or dip into for reference, the chapters are relatively short and contain conclusion and/or summary sections. The excellent summary of the book at the end draws the principles together. Corinne Dobinson is a research and clinical speech and language therapist working for the University Hospitals of Bristol NHS Foundation Trust. She has a special interest in processes that assist transfer and generalisation.


Using Intensive Interaction with a Person with a Social or Communicative Impairment Graham Firth & Mark Barber Jessica Kingsley ISBN 978-1-84905-109-5 12.99

Practical and enjoyable


Generalization of knowledge: Multidisciplinary perspectives Marie T. Banich & Donna Caccamise (eds.) Psychology Press ISBN 978-1-84872-898-1 47.50

Only for enthusiasts

This book evolved from a conference, which aimed to draw together multidisciplinary perspectives on generalisation, in order to identify some general theoretical principles. The perspectives are from the fields associated with cognitive science, including education, linguistics, developmental science and speech and language science. Language development and processing are often used to exemplify points and some chapters specifically deal with these. One, on generalisation in language learning, draws from the field of aphasia (specifically agrammatism), while another describes how children use generalisation processes to create categories in language acquisition. However, the reader would require a grasp of both subjects to fully appreciate their content. This book would benefit those with an academic interest in generalisation, and some clinicians may find certain chapters useful. However, its jargonistic style is likely to make it accessible to only the most enthusiastic reader.

This is a practical, enjoyable, easy-to-read guide, whose title does not do the contents justice. Stepping away from academia, this book is of equal value to those wishing to dip their first toe in as it is to those needing to structure substantial experience into bite sized pieces for training and supporting others. The authors start with explaining how Intensive Interaction relates to what we all do when we get to know people. They address key questions of how to start, progress through and evaluate sessions, and finish with discussion of how to develop competencies. Although it is very reasonably priced, the format is not easily accessible to carers and support workers who, unlike therapists, dont get paid study leave or necessarily have a culture of book reading. I was left wanting Graham and Mark to reformat this book into handouts to complement the DVD or a training session, or worksheets that could be used to evidence competencies of speech and language therapy assistants or carers. Caroline Hucker is a speech and language therapist working in community learning disability teams across the five boroughs of Aneurin Bevan Health Board.

Easy to read with a very comprehensive index, it is a good insight into inclusion, and is full of tried and tested advice for whole class, small group and 1:1 teaching. User friendly chapters on individual practical strategies include Oops cards and visual conversations, which were new to me. I tried them out successfully and have added them to my strategy bank. There is a chapter dedicated to awareness of break times and mealtimes. These are difficult times for any child with Asperger Syndrome, and so easily overlooked. This book makes sense of a very complex and varied disorder. It is written by an author with firsthand experience, and lots of common sense, who obviously knows what she is talking about. Caroline Causier is a teaching assistant in a mainstream primary in Worcester, supporting children with speech and language difficulties, autism spectrum disorder and general learning difficulties.


Adaptive Origins Evolution and Human Development Peter LaFrenire Psychology Press ISBN 978-0-8058-6012-2 40.00

Hugely interesting


Working with Asperger Syndrome in the Classroom An Insiders Guide Gill D. Ansell Jessica Kingsley ISBN 9781849051569 12.99

In this book, LaFrenire explores the interdependence of evolution and development giving an insight into how we have become what we are a unique species with origins common to all of life. He takes us through the evolutionary development of human behaviour, including communication and social interaction, from early hominids to modern humans, from prenatal hormones to infancy on to maturity relevant to anyone interested in people, not only speech and language therapists. The thirteen chapter summaries make it easy to decide what to read in more depth a boon for busy clinicians and students alike. It has some difficult terminology but a comprehensive glossary. Although not clinically necessary for most practising therapists, this is a hugely interesting book; too expensive for a casual read but great from the library. Katie Cullinan is a paediatric speech and language therapist in London.



This is an excellent book for all practitioners within the educational, health and independent sectors who come into contact with children with Asperger Syndrome. It is essential for Special Educational Needs Coordinators and teaching assistants, and also suitable for early years practitioners.

Ethics in speech and language therapy Richard Body and Lindy McAllister Wiley-Blackwell ISBN 978-0-470-058886-6 31.99

An excellent resource

This is really thought-provoking far from a dry, dull book about ethical theories and principles. These are the focus in the first



two chapters, though readily applied to and concentrated on everyday speech and language therapy practice. Therapists and managers working in a range of settings and with different client groups (or students learning about them) will recognise their real worlds in the scenarios presented in innovative ways in chapters 3-7, for example hard to access children, or people with aphasia in acute hospital wards who do not receive a fair amount of therapy. The discussions and commentaries around the scenarios make clear there is no easy answer to the many awkward or difficult situations in which we can find ourselves, just possible ways ahead. They take the reader beyond the individual case to more general ethical questions, including whistleblowing and the impact of health consumerism on areas where it is difficult to offer the optimal intervention. Chapter 8 looks at management level ethics, including allocating resources (very topical in the current financial climate!) This book is an excellent resource for helping us think more deeply about our work-related ethical challenges. Linda Armstrong is a speech and language therapist with NHS Tayside in Perth & Kinross (see also Boundary Issues on p.25).


The Eyes Have IT! The Use of Eye Gaze to Support Communication. Collected Papers from the 20th Annual Augmentative Communication in Practice: Scotland Study Day Allan Wilson & Rebecca Gow (eds.) CALL Centre ISBN 978 1 898042 32 7 7.00

Roger D. Newman is a highly specialist speech and language therapist at Lancashire Teaching Hospital NHS Trust.


Standard we expect


Improving Working Memory (Supporting Students Learning) Tracy Packiam Alloway Sage ISBN 9781849207485 21.99

Whether an old hand or an eye gaze technology novice, this small, easily readable collection of papers offers more than its appearance suggests. The papers cover a variety of the aspects of Eye Gaze, including hardware, software, assessment, application, users experiences and even ethics. Papers are from both prophets and converts to the technology. The reader is led to both question and ponder on their content. The book offers a comprehensive introduction to eye gaze, whilst also identifying with the dilemmas others have already faced, at times providing possible solutions. Yet again the editors and the CALL centre have attained the standard we have come to expect of their publications informative and well priced. A wide variety of readers will find this useful. Angela Hunter is head of the speech and language therapy department at Hollybank Trust, Mirfield, West Yorkshire.

Knowledge Translation in Health Care Moving from Evidence to Practice Sharon Straus, Jacqueline Tetroe & Ian D. Graham Wiley-Blackwell ISBN 978-1-4051-8106-8 35.99

Academic detail

This book brings together a wealth of expertise in the science and theories behind how knowledge is created, analysed and used by different decision makers in practice. Contributed to by many academic experts in the field, it provides in depth analysis of models and theories in this topic. For anyone wishing to understand the depth of models and research in this field it would provide them with the academic detail. For practising clinicians there are small elements written less academically that are practically useful, however it is likely that other resources available may meet these needs in a more accessible format. Satty Boyes is the clinical lead for the adult acquired service in Salford. In addition to her management role she carries a clinical caseload in neuro critical care.


Succinct and useful

Building a Research Career Christy L. Ludlow & Raymond D. Kent Plural ISBN 978-1-59756-227-0 57.00


This book has a broad appeal from student speech and language therapists to experienced practitioners. The premise is to identify and support pupils with working memory difficulties. It establishes the difference between short term memory and working memory, and illustrates how crucial working memory is in the learning process. Chapter 2 looks at the pros and cons of assessments of working memory. The following chapters cover dyslexia, dyscalculia, dyspraxia, attention deficit / hyperactivity disorder and autism spectrum disorder with a memory profile and support strategies for each. The design of the content is attractively presented. The text is broken up with case studies, research and mini challenges. The chapters on disorders provide basic information, useful facts and some thought provoking points, and the layout allows each one to be read independently. At 110 pages, it is succinct, good value and a useful tool for the workplace. Gillian Lord is an ASLTIP speech and language therapist in Oldham and Saddleworth.

Medical perspective

CHARGE Syndrome Timothy S. Hartshorne, Margaret A. Hefner, Sandra L.H. Davenport & James W. Thelin Plural ISBN 978-1-59756-349-9 51.00

This book provides excellent advice regarding selecting a doctoral programme, particularly the relative importance of the different aspects. It places selection of a mentor above the area of interest, department, university and facilities and support, and provides guidelines should the initial plan fail. It reinforces the fact that you are selecting the mentor as much as they are selecting you. However, although doctoral training may be the most important aspect for professionals wishing to undertake a research career, this only covers a very small part of the text. The authors provide sound advice which universally covers all aspects of research, but from the perspective of a very medical model. Along with the very American orientation, this is not always applicable. However, keeping current and organising information show a good overall model of how to keep abreast of competition and new information, and provide hints regarding careful documentation and data management.

Worth digesting

If you are looking for more information about CHARGE syndrome, this book provides a comprehensive, multidisciplinary guide to the complex condition. Each chapter is written by a specialist in a particular field covering sensory, medical, communication, developmental and psychological issues. The introduction captures your attention from the outset with the words communication, communication, communication. There are three chapters focused on the assessment, forms and functions of communication which provide a useful reference guide, especially to those new to working with children in this area. Although the book does not lend itself to instant practical ideas, it is worthwhile spending some time digesting the information to gain a better understanding of the challenges which face these children. Bryony Aitken is a speech and language therapist at Sandwell PCT.



Whose goal is it anyway?

Part 2: Getting the process right
In the second of a four part series, Sam Simpson and Cathy Sparkes offer a flexible framework for a goal negotiation process that takes clients, families, therapists and teams from the first meeting through to preparation for discharge in acute, rehabilitation and community contexts.
n this series we hope to challenge and develop your understanding and practice of client-centred goal negotiation. In our first article we defined frequently used terminology and considered the key principles that underlie effective client-centred goal negotiation. In this second article we examine the actual goal negotiation process. Some of you will work in successful interdisciplinary teams or as a single discipline where the goal negotiation process is well established and understood by professionals, clients and families. Others will be working in a team or as a uni-professional where the idea of a framework for goal negotiation feels far from reality. We invite you all, however you are currently working, to assess the level of client involvement within your service and to reflect on the proposed process outlined in figure 1. This process has been borne out of many years of clinical experience and commitment to client-centred goal negotiation as the backbone of cohesive interdisciplinary team working. It is the result of considerable client, family and multi-professional consultation and review, which has been further influenced by the cross-fertilisation of different theories and research into goals across a range of disciplines. We will describe each step in loose terms, but ask you to bear in mind the service within which you work. Consider this a flexible framework to be adapted in accordance with your work context, not something to be applied rigidly and unquestioningly. For ease, we have divided the process into three phases: READ THIS IF YOU WANT THERAPY TO BE MORE CLIENT-CENTRED MEANINGFUL FOCUSED

Cathy and Sam

This can take a variety of forms: face-to-face in either a 1:1 or group therapy session, through the use of information leaflets, handbooks or information boards. Time allocated to explaining the goal negotiation process enhances a clients knowledge of the service they have entered into and how that service is delivered in addition to its specific remit and boundaries. This is integral to managing both client and professional expectations from the outset, clearly delineating roles and promoting the clients engagement in rehabilitation. 4. Initial goal exploration The next stage involves an open exploration of lifestyle issues, wants and aspirations with the client and their family. It is a loosening process, enabling the client to identify broad life domains and priorities at that point, from which potential rehabilitation goal areas can be established. This is a crucial stepping stone to eliciting more focused client-centred goals. This preliminary discussion can be facilitated by the keyworker or by an allocated team member for and on behalf of the team. It takes the form of a supported conversation with visual frameworks such as mindmaps and time lines that can then be shared with family and other team members to promote further discussion.

be negotiated in order to avoid unnecessary duplication and also for a key worker or coordinator to be assigned, if appropriate. Close cooperation and communication is encouraged as professionals can share information regarding who is doing what, how frequently and in what location. 2. Identification of strengths, needs, wants and issues The next step involves drawing up a list of the clients strengths, needs, wants and issues on admission. The multidisciplinary team provides evidence in support of the clients viewpoint and also to supplement this, through ongoing assessment and the start of intervention. This is an important stage as it ensures the client and their family remain at the centre of the information gathering process and reminds the team to keep documentation a priority. To draw up this list, sessions with the client and/or their family can be held with one discipline or with two or more together depending on the issues to be discussed. Assessment review and feedback of results can also be an important part of this process. 3. Explanation of the goal negotiation process This stage is often omitted as professionals frequently assume that clients and their families are familiar with the processes involved in goal planning and negotiation. However, this is invariably not the case, and it is important to provide regular accessible information about the actual goal negotiation process.

5. Developing the prerequisites for goal negotiation A clients capacity to negotiate meaningful goals will depend on their individual personality, life experience, degree of emotional stability, level of cognitive understanding, and capacity for mature reflection, self-understanding and decision making. It is important to recognise that goal negotiation is a complex skill and not to expect that all clients will be able to engage in the process readily. Indeed, you may need to allocate time to foster the foundation skills involved in goal negotiation and to establish a clients potential for change. While we believe it is crucial to respect a clients pace

1. Assessment liaison This first step refers to the point when a client enters your service. Ideally, each team member will have had the chance to meet with and informally assess the client and their family, and is consequently ready to share their preliminary thoughts and concerns regarding the clients admission with other members of the team. Liaison with all professionals involved at this early stage allows for roles to




1. Assessment liaison A. Initial phase 2. Identification of strengths, needs, wants and issues 3. Explanation of the goal negotiation process 4. Initial goal exploration 5. Developing the pre-requisites for goal negotiation B. Ongoing phase 6. Further goal exploration as required 7. Goal negotiation and elicitation 8. Initial and ongoing goal negotiation meetings 9. Final goal negotiation meeting C. Preparation for discharge 10. Scoring / audit 11. Documentation including report Figure 1 Goal Negotiation Process

helpful. One commonly used is: A = Achieved P/A = Partially achieved N/A = Not achieved. Additionally, a set of variance codes can give an indication of why a particular goal was not achieved. These are often divided into broad categories such as those relating to the client (eg. unwell), the healthcare professional (eg. therapist off sick), resources (eg. equipment not available). The scoring systems can help the client to understand the reasons why a certain goal was not achieved and can also be used for audit purposes. Regular, well documented goal review meetings are an essential part of maintaining a focus for rehabilitation and a method for reviewing the effectiveness of intervention. The multidisciplinary team needs to remain clear as to the purpose of the goal review meetings and determine the need for separate meetings such as case conference or discharge planning as appropriate.

and readiness to formulate their own therapy goals and direction, we appreciate this can be at odds with lean working principles. Investing time in supporting the development of the prerequisite skills involved in goal negotiation will in turn increase a clients engagement in the therapy process through greater selfknowledge, a more solid understanding of therapy (possible benefits, limitations and the role they have to play) and a greater appreciation of their personal potential. The necessary prerequisites for goal negotiation can be developed through joint sessions with family/friends and the client, targeted assessment and review, video feedback, 1:1 and group community visits, education sessions, re-explanation of the goal negotiation process, task analysis, and exploration of the pros and cons of a particular behaviour. 6. Further goal exploration Essentially this involves repeating stage 4 as appropriate and offering the client more time to explore and establish potential goal areas and priorities. They can then progress to the formulation of more focused goals. 7. Goal negotiation and elicitation This stage can be considered a tightening process. The information gathered from the goal exploration sessions (A4 and B6) is further discussed with each discipline involved in order to establish more focused client-centred goals. Frameworks that can usefully facilitate this include prioritisation, rating scales and steps, and option appraisal. The contract comprises a shared agreement across the team on the focus of therapy within the context of the service offered over an agreed time frame. The goals negotiated structure the rehabilitation process and provide the foundation for therapy across the entire team. Furthermore the clients high level of involvement in negotiating this management plan serves to enhance

their commitment and understanding of the process. The keyworker or an allocated team member is tasked with coordinating and disseminating the final document detailing all of the agreed goals. This needs to be in a format that is accessible to the client and their family as well as the team. 8. Initial and ongoing goal negotiation meetings Regular goal negotiation meetings provide a useful forum to agree on and review all longterm/discharge goals, short-term goals and plans of action. We use the term meeting to indicate a more formal opportunity to discuss the goal planning process. Who actually attends may vary across time according to the individual client and structure of the team. At the very least it will involve the client and a key professional, however family and friends (at the clients request) may also be present, as well as one or more members of the multidisciplinary team. While the meeting can take place in a variety of locations depending on where the client feels most comfortable - their own home, a lounge, a more formal meeting room - it is important that the environment is quiet and undisturbed, and signals the level of importance given to the discussion. These meetings focus solely on formalising the goals negotiated, intervention plans and roles across the team. Clear documentation of goals and the decisions made in each meeting is essential for the client, the family and all healthcare professionals, especially if not everyone is present. The frequency of meetings (weekly, bi-weekly, monthly) to review all subsequent goals and dates/times need to be agreed by everyone involved. The frequency negotiated will also need to balance the realities of caseload/time pressures for the team with the need to keep the focus and momentum for the client. When each goal is reviewed a system of scoring (agreed by and clear to all) can be


9. Final goal negotiation meeting In preparation for discharge this final goal negotiation meeting should include some or all of the following so the client and their family have the opportunity to celebrate successes and identify future paths: A review of the most recent long-term and short-term goals A review of the overall intervention package An evaluation of the intervention process from the clients perspective An opportunity for endings from the current service and possibly introductions to the next service The identification of possible future goal areas. 10. Scoring / audit As referred to in B8, a scoring system can be of help to the client, their family and the service as a whole. As with all aspects of this process, it is important that the system works well for the context within which it is used. 11. Documentation including report Clear written communication is essential throughout a clients admission, both for the team and for the client and their family. This can take a variety of forms including the use of an assessment liaison checklist to standardise the process, written information for the client about the goal planning process, multidisciplinary or single discipline notes, a specific goal planning section within the medical notes, written copies of goals or goal areas in a format accessible to the client, written minutes of meetings, variance codes. It can also be beneficial to use the goal negotiation process as a framework for a single discipline/multidisciplinary team report when referring on.




This goal negotiation process can be used flexibly depending on the setting you work in. Here are some of our ideas for different service areas: a) Acute Therapists in acute settings often report difficulty translating the goal negotiation process due to the status of clients and the short time they remain within the service. We recommend prioritising the early stages, in particular gathering information about the client from a team perspective through interviews, single or joint assessments, and the use of pre-injury questionnaires. Robust documentation systems and lines of communication assist further. Family and friends are often readily accessible and can usefully be involved to formulate a comprehensive picture of the clients past and present situation. Clear feedback, information and education opportunities will promote client self-awareness and development of the prerequisite skills for goal negotiation. For those who remain longer in the acute setting, establishing a transparent prioritisation system enables therapists to identify clients who are appropriate for the subsequent stages of goal negotiation. Thus it may be possible to negotiate some short-term (2 to 5 day) impairment or activity-based goals under a broader goal area with specific clients. Look for flexibility and any opportunity for dialogue around potential goal areas. Encourage links with real life to facilitate the elicitation of meaningful goals (looking through a favourite magazine together, a cup of tea at bedside jointly with a family member, a visit to the coffee shop, garden or local shops). As and when a client transfers onto the next service, this will be invaluable. When therapists offer information to clients about any post-acute services it can be useful to introduce the concept of goal negotiation and the integral role that it will play in rehabilitation. Interdisciplinary working and a shared commitment to the goal negotiation process can be supported by having an allocated goal negotiation coordinator, who ensures induction and training programmes to all staff and the establishment of working groups to support its ongoing development.

b) Rehabilitation Whilst it can be helpful for some clients to have time away from their home to reframe their present situation, skills and abilities, for others an inpatient rehabilitation setting is artificial and overly institutional. Regular links with real-life contexts (sessions over lunch or coffee, group opportunities, community visits, home visits) facilitate the elicitation of meaningful goals and provide clients with tangible ways to move forward. Take a moment to reflect on why clients come to your rehabilitation service, and whether the timing of admission is something you or they have any choice over. Consider also how time is framed and time boundaries determined. Does your service offer a standard time-limited contract (6 to 12 weeks) or are more discrete, flexible packages negotiable (an assessment package, a review package, an individual or group therapy package, a graded admission, a graded discharge), thereby allowing therapy to be adjusted in accordance with a clients readiness for change and the focus of therapy? To what extent is the service you offer at a multidisciplinary or single-discipline level really tailored to what your clients want and need across time? Interdisciplinary working, shared commitment to the goal negotiation process and flexibility are all key components to any rehabilitation service and enable clients to make the most of their time with you. It is possible for multidisciplinary team members to work in series as opposed to in parallel to cater for differences in a clients readiness to change. We recommend the allocation of a goal negotiation coordinator, the development of induction and ongoing training programmes as well as multidisciplinary working groups and regular consultation with clients, their families and friends. Attention also needs to be given to the development of robust documentation systems and lines of communication in addition to clear and timely information exchange on transfer. These systems and approaches in the rehabilitation environment truly serve to offer the client more person-centred, flexible and timely interventions. c) Community When clients leave the confines of an institution to embark on life back in the real world, they are entering a context that arguably has the greatest meaning to them. Working within the community has the advantage of increasing

the range of locations where therapy can take place (at the clients own home, in a coffee shop, pub, day centre or multidisciplinary outpatient service), thereby promoting links with real life and the negotiation of meaningful goals. There is also often greater flexibility and availability to involve family and friends in therapy. We recommend flexible frameworks for service delivery over standard time-limited contracts, as this allows for structured agreements related to the duration and focus of any particular therapeutic relationship. Similarly, interdisciplinary working in series as well as in parallel also allows for greater flexibility and timeliness of intervention across the team. The unpredictability of the community context and personnel creates particular challenges for therapists and has significant implications for the infrastructure and process of goal negotiation across a team. Consequently, a cohesive goal negotiation process agreed by all professionals in addition to robust documentation systems and lines of communication are all key. Clear information on the service especially its remit and boundaries and end points is also critical. Having an allocated goal negotiation coordinator to develop induction and ongoing training programmes as well as a multidisciplinary working group also supports the ongoing development and review of the goal negotiation process.
PRACTICAL ACTIVITY: Your goal negotiation service Identify aspects of the proposed goal negotiation process that are in line with your existing service, and consider possible development ideas. Remember the process is a flexible framework that can be used differently according to the service you are working in and the client you are working with.

In our next article, we will focus on the clients voice through exploring a 6-stage model of readiness to change, and on the actual goal negotiation conversation in a range SLTP of contexts. Sam Simpson (email is a specialist speech and language therapist and trainee counsellor. Cathy Sparkes is a specialist speech and language therapist and counsellor. Together they are intandem (


Safe and soothing drinks for dysphagia. Keep your patients healthily hydrated.

t: 08452 222 205 e: w:



Heres one I made earlier...

Cynthia Pelman with a low cost, flexible and fun suggestion Bookmaking
We therapists use narrative in many different ways - for assessment, to target skills such as story grammar, and to focus on specific aspects of phonology or language. Those working in schools are especially likely to use narrative, as so much of school work involves recalling and retelling past events in their correct sequence and in sufficient detail. Our emphasis is of course on oral and not written storytelling and language. But making a book does not mean taking away this emphasis; nor am I suggesting that the children should necessarily write their own books (although some really love to). I do, however, encourage children to make their own books. If we can record a story in a concrete way - through pictures (stick men drawings or downloaded images work equally well) and through the therapist scribing what the child has said, it provides a lovely way to celebrate the childs achievement. It creates a permanent record to take home, as well as offering opportunities for repeated oral output though retelling the story to family and friends. MATERIALS There are endless ways to make a book, and all are simple enough for the child to do most of the work (with supervision for use of glue and scissors). The children I work with use a range of different methods to create their books. There are some wonderful websites which provide clear instructions for bookmaking, and once you get into it your own imagination will take over. You dont need expensive materials - scraps of cardboard, cereal boxes, glue, glitter and coloured pens will take you a long way. The binding of the book is the most technical bit. The simplest way is to staple some pages together and make a cardboard cover. But children love to be able to create something more attractive and interesting, and to choose their own book design, so here are some more ideas: 1. An easy method is to use a few blank cards stapled or linked with treasury tags; the child can illustrate a cover and you have a book which can be taken home and re-told to their family. You can also use packaging labels (the ones with one hole pre-punched and strings attached) to make a fun little book. 2. Cut out as many pages as you will need, and cut a cardboard cover folded in half to contain the pages. Punch two holes through the left side of the pages and the cover. Hold a long elastic band at the back of the book and insert the top looped end from the back to the front into the top hole, and the other looped end into the bottom hole. Catch both loops with a pencil .That way you can always take the book apart, use the pencil to add more pictures, and put it together again! Make sure that the illustrated pages inside have a good 3cm margin on the left to allow for punching and bending. I usually draw the margin in so that the children are not tempted to draw right to the edge. 3. Another simple way to bind pages with two punched holes is to use a shiny narrow ribbon threaded through and tied in the front with a bow. Make sure to score and bend the front cover about 1cm to the right of the punched holes so that the cover opens properly. Craft shops sell lots of tiny pretty flowers on wire stems which you can wind around the ribbon. You can use shiny or fluorescent coloured card for the cover, or decorate with glitter and pictures. 4. Cut 3 pages of A4 in half or thirds lengthwise, and glue the ends together to make a very long thin strip of paper. Fold in a concertina style (like a fan) so that each fold gives you a decentsized page (about 7 cm wide). For the cover, fold a piece of card in two. Glue one end of the concertina to the front inside cover and the other end to the back inside cover and you have a book with lots of pages! Children love to open up the concertina, which is really long, and then to fold it back in. 5. An additional decorative detail, and one which usefully holds the concertina book closed, is to cut a thin strip of very unusual paper (wallpaper or gift wrap scraps are good) about 4 cm wide and long enough to go all around the book, to make a little sleeve into which you can slip the book. The sleeve should slip off easily so that the child can open the book quickly, but not be so loose that it falls off. 6. See for a quick, easy and inexpensive way to make a little book with a single sheet of A4. 7. Make a fabric cover for a simple stapled book. Furniture upholsterers and fabric shops often discard their old fabric sample books. The child can choose a fabric and cut it out to be the same size as a cardboard cover (old cereal boxes are good). To attach the fabric to the card, bend and score the card first so the fold is ready and then glue the fabric onto the cover with white glue while the cover is bent closed (otherwise the fabric will not be big enough to accommodate the fold and will distort the card). 8. You can make a wallet-type of cover with fabric and card which wraps around the book and is closed with a ribbon. The wallet cover is folded in three: each piece should be the same size as the book. The middle part goes over the back of the book and the two sides are left loose to wrap around the book. Use a colourful ribbon to tie it up; it is best to fix the ribbon with a stitch or split pin onto the edge of the front wrap so that it doesnt get lost. 9. A fun way to illustrate a front cover is to draw the characters in the story on the front and to glue plastic eyes onto the characters. Craft shops sell lovely little plastic eyes with moving bits for the pupil and a flat back for glueing. You can also use scissors which cut a wavy edge to give shape to the pages and the cover. RESOURCE More ideas at IN PRACTICE The use of oral storytelling is of course primary, and is the earliest entry for the young child into the world of narrative. It is important however to keep in mind both input and output for narrative (as for any other therapy activity). If we are modelling a rich input by reading or telling a story, and by expanding the childs contributions, we risk taking up too much of the air time and not giving children the opportunity or time to create their own stories. Make sure that the child is given time and encouragement to make up their own stories and to tell and retell them to a range of listeners. I have found that providing extensive and frequent opportunities for output has made a big difference for children who were once shy or reluctant to make up their own stories; in addition, it sometimes develops their expressive language more effectively than modelling and expanding.



Communication on probation
hen a defendant is found guilty of a crime, judges and magistrates typically have three sentencing options: a fine, a community sentence or prison. Community sentences allow offenders to undertake rehabilitative programmes and work in the community whilst under the supervision of the probation service. According to the Howard League of Penal Reform, the last ten years have seen an increase in the number of community sentences handed down. Judges and magistrates can select up to twelve different requirements, including unpaid work, participation in specific activities such as literacy or basic skills, and accredited programmes. Contact with the probation service often involves verbally mediated interventions, either in one-to-one meetings with probation officers or group-based programmes aimed at changing offending behaviour and drug / alcohol treatment. Failure to comply can result in the offender being in breach of the court order and possibly being sent to prison. Despite this, little consideration has been given to the possible impact of speech, language and communication difficulties for offenders completing community sentences. In 2010 the Wales Justice Coalition was formed to bring together stakeholders interested in speech and language therapy and criminal justice, including the Royal College of Speech and Language Therapists, the Welsh Assembly Government, academics, and individuals working in courts, prisons and the Wales Probation Trust. The Coalition aims to raise awareness within the Welsh Assembly Government, criminal justice agencies and other organisations about: i. the high numbers of people with speech, language and communication needs in the justice pathway ii. the impact this has on their chances of reoffending and iii. the role of the speech and language therapist and others in addressing these needs. According to Locked Up and Locked Out (Wales Justice Coalition, 2010), speech,


Rachel Iredale, Beth Parow and Harriet Pierpoint undertake an exploratory study of speech, language and communication difficulties among offenders completing community sentences, and consider its implications for future studies and speech and language therapy services.



language and communication difficulties are positively associated with low attainment, behavioural problems, mental health issues, poor employment prospects and, importantly, criminal behaviour. Although most research studies have focused on basic skills needs of offenders and conditions such as dyslexia and attention deficit/hyperactivity disorder, studies by speech and language therapists have found that between 50-90 per cent of offenders may have communication difficulties (Bryan, 2004; Bryan et al., 2007; Snow & Powell, 2005; 2008). However, the majority of this research focuses on convicted offenders - typically male juvenile offenders and the suitability of prison programmes. For example, Bryan et al. (2007) found that up to 67 per cent of 58 young offenders detained at a young offenders institution in England had poor language skills, whilst Moseley et al. (2006) discovered that, when offenders are supported to improve their language and communication skills, recidivism rates fall by as much as 50 per cent.

Speech and language therapists can become registered witness intermediaries, helping witnesses who have communication needs to give their best evidence in criminal investigations and trials. However, there has been very little work done on how they could assist adult offenders moving through the criminal justice system. We carried out an exploratory study to investigate the presence and perceived impact of speech, language and communication difficulties among offenders completing community sentences in South Wales. Ethical approval was obtained from a Faculty Ethics Committee at Glamorgan University and from the National Offender Management Service (NOMS). Access to offenders was arranged via managers at a local probation service, and participants were recruited during one week spent by a speech and language therapy researcher at the probation office. They were recruited either on the recommendation of staff who had concerns about their communication skills, or through observation by the therapist.



Information about the study, and consent forms, were read aloud to the offenders, and everyone was given the option to opt out at any point without providing a reason. All assessments, observations and interviews were administered by one researcher. The project was explained to 27 people, and 10 agreed to take part. The 17 offenders who did not participate either did not give consent or did not attend their pre-arranged appointment, illustrating how difficult it can be to engage with this population. Seven participants were male and three female. They were aged between 21 and 49 years with a mean of 31. All had English as their first language and none had attended a special school. There were two parts to the study a screen and a semi-structured interview. 1. SCREEN We reviewed a range of tools used by speech and language therapists working with offenders in clinical practice and research, and devised a screening test. We screened the participants for possible communication difficulties using the sections of the Broadmoor tool (Bryan, 1998) most relevant for skills needed in a criminal justice setting. We added the Pool Table Assessment (Gregory, 2008), which involves asking a participant to re-tell a sequence of events Tell me how to set up a table for a game of pool and tell me how you win. Our screening tool covered: a) Direct assessment Comprehension: listening to, and answering questions about, a short story (the auditory comprehension subtest of the Broadmoor tool) and making sense of complex sentences (the logicogrammatical relationships subtest of the Broadmoor tool) Expressive language: creating a sentence with target words (the sentence construction subtest of the Broadmoor tool) and re-telling a sequence of events (the Pool Table Assessment) b) Indirect assessment through observation Social communication skills, conversational skills (including topic maintenance and relevance) and non-verbal communication skills Fluency Speech clarity. Data from the direct assessment was interpreted according to test guidelines. Scoring on the indirect assessment through observation was compared to what the researcher would expect of a member of the general public. To increase reliability, participants were only classed as having possible difficulties with comprehension and expressive language if they scored below the range expected for both subtests within the section. 2. SEMI-STRUCTURED INTERVIEW This explored offenders perceptions of: a time when they could not understand what people were saying at court / probation

Figure 1 Offenders with different types of communication difficulty 6 Number of offenders 5 4 3 2 1 0 Comprehension Expressive language Social communication Speech Stammer

Types of communication difficulties

a time when they could not explain what they wanted to say at court / probation who and what would have made it easier for them to understand or explain what they wanted to say in court / probation. The researcher also asked participants to define vocabulary items regularly used in the criminal justice system, such as custodial, alleged and remorse (based on Crew & Ellis, 2008). The use of a semi-structured interview schedule meant questions could be asked differently to ensure offenders understood. They could also be adapted to accommodate every offenders particular circumstances. Every interview was audio recorded and transcribed verbatim. All authors analysed the transcripts thematically (Burnard, 1991) to include the nature of the communication difficulty, the impact of the difficulty on the offender and the problems they encountered, and who or what would have helped overcome the difficulty. We anticipated it would be problematic for offenders to attend two pre-arranged appointments, so the screen and the interview took place during the same session. The average time for both was 50 minutes. All screening subtests were completed by nine of the ten participants; one offender did not complete the entire assessment due to another appointment with the probation service. Only one of the ten appeared to have no speech, language or communication needs. Figure 1 shows the type of speech, language and communication difficulty identified. Five people had difficulties with both comprehension subtests and four had difficulties with both expressive language subtests. (One offender did not complete the entire comprehension subtest.) Three participants had difficulties with both comprehension and expressive language. Five people had difficulties with social communication. Two people had speech issues (for our purposes, this included problems with intelligibility, articulation, rate, resonance, intonation and volume) and one had a mild stutter. The main categories of difficulty reported by the participants were:

Not understanding legal terminology Disengaging from the criminal justice process Emotional and behavioural effects. Several affected offenders explained they had not understood the nature of their sentence:
Well, it was actually the security court people like, you know, who said, you know, you're free to go like, you know. I thought they were taking me back down again, you know, for 12 months like. Offender 9, difficulties with comprehension

However, the offender who was deemed not to have any communication difficulties was also unclear about the nature of their sentence:
In court, they said a word and I didnt understand what it meant.asked solicitor what judge meant and he told me and I was getting sentenced to prison. Offender 4, no communication difficulties

The results of the vocabulary definition task also illustrated widespread difficulties understanding terms regularly used in the criminal justice system. Only one of the ten participants attempted to define reparation; seven thought compensation was money they should receive; three could not define remorse; seven did not understand revocation and four could not define custodial, including one who had been in prison before. During the interviews, the researcher asked participants about their communication difficulties. They gave examples of when they perceived these to have impacted on their ability to access programmes in the probation service. Disengaging was one effect of not understanding the language used:
Youre like Like what does that [mean], and you think God, just let it go over your head like. Whats the point like. The quicker you are in here, the quicker youre out. Offender 3, difficulties with all aspects of communication Sometimes its easier to tune in and sometimes its easier to switch off. Offender 7, difficulties with non-verbal communication



According to participants, disengagement could also occur if they did not ask for clarification during sessions with probation officers. However, they also expressed fear of being in breach of the sentence handed down by the court, and possibly being sent back to prison:
I have got to I have got to ask them like what do you mean and things like that, if Im not sure... because if I dont, they wont tell me and Ill get breached. Offender 7, difficulties with non-verbal communication

Offenders also talked about how they felt when they were experiencing communication difficulties, and some described self-loathing and paranoia:
Terrible, terrible. I feel really terrible. I think what an idiot I am. Im not really good. Im loathe myself, I do. Offender 8, difficulties with expressive language, comprehension, non-verbal communication and a stammer Its just you thinking Oh, did I just said that word right, or?. So youre just paranoid then, then someone might not be able to understand what youve just said. Offender 3, difficulties with all aspects of communication

Other offenders admitted their communication difficulties had a negative impact on their behaviour and their ability to complete the requirements of their community sentence:
If Im too quick with my words, or I get if I cant get something out Ill get nastyish and then Offender 3, difficulties with all aspects of communication Well I would have been stuck behind, stuck behind, know what I mean? . and you just get agitated then do you know what I mean? Thats when you find yourself in trouble then. Offender 6, difficulties with comprehension, conversation and speech sounds.

The results of the screening assessment in this pilot study with adults are consistent with the findings of larger studies into young offenders: communication does seem to be a problem. We found that difficulties with social skills were as common as those with language, so this should be investigated in future studies. Most participants described the worrying effects of their communication difficulties on their experience of the criminal process and probation, including not understanding the requirements of their sentences, disengaging and becoming agitated. Occasionally offenders without comprehension difficulties also gave examples of times they had not understood language used, particularly in relation to their sentence. This illustrates how impenetrable the criminal justice system can seem. A more detailed and refined assessment than our screening tool would fully diagnose the

nature and extent of communication difficulties amongst offenders in the community. There is no published standardisation data for the assessments we used, and no existing standardised assessments were appropriate as a rapid screen. We cannot be sure how or to what extent having to be informed and consent to the study in the same session as the assessment affected communication skills. Our results should therefore be interpreted cautiously. Further research should explore the relationship of speech, language and communication difficulties to the completion of community sentences, including the use of a control group of offenders without these difficulties. Our findings need to be confirmed in larger-scale studies before making any firm recommendations for practice. However, combined with the existing literature, they have implications for the way offenders are identified as having problems and communicated with as they progress through the criminal justice system. Speech and language therapists have a role to play in future service delivery to help offenders complete community sentences. We need to consider whether already stretched community services can simply absorb a role extension, such as working with adult offenders, or whether additional funding is required to properly meet their needs. We know that much of the supervision of offenders by the probation service is predicated on their ability to benefit from verbally mediated interventions, such as enhanced thinking, anger management or drug-related group work. Failure to comply can result in offenders being in breach of these community sentences. Speech and language therapists therefore also have a role in training others working in the criminal justice system, sharing information about individuals communication skills with key members of staff and suggesting how to make programme requirements more accessible. We believe such measures are required urgently to give offenders the fullest chance of understanding and engaging with the criminal justice and rehabilitative system. The Wales Justice Coalition - which we were invited to join on completion of this study - and the Royal College of Speech and Language Therapists Criminal Justice Campaign have an important role. As Lord Ramsbotham, former Chief Inspector of Prisons, once said,
I have to admit that in all the years I have been looking at prisons and the treatment of offenders, I have never found anything so capable of doing so much for so many people at so little cost as the work that speech and language therapists carry out.

CRITICAL FRIENDS With thanks to Jan Mitchell and Jackie Freer, both forensic speech and language therapists in Northumberland, who peer reviewed the first draft of this article for Speech & Language Therapy in Practice.
References Bryan, K. (1998) Broadmoor Hospital Speech and Language Therapy Initial Assessment. Unpublished. Bryan, K. (2004) Preliminary study of the prevalence of speech and language difficulties in young offenders, International Journal of Language and Communication Disorders 39(3), pp.391-400. Bryan, K., Freer, J., & Furlong, C. (2007) Language and Communication Difficulties in Juvenile Offenders, International Journal of Language and Communication Disorders 42(5), pp.1-16. Burnard, P. (1991) A method of analysing interview transcripts in qualitative research, Nurse Education Today 11, pp.461-466. Crewe, M. & Ellis, N. (2008) Speech and Language Therapy within Bradford Youth Offending Team. Unpublished Report: Bradford NHS & Bradford & District Youth Offending Team. Gregory, J. (2008) Pool Table Assessment. Unpublished: University of Surrey. Moseley, D., Clark, J., Baumfield, V., Hall, E., Hall, I., Miller, J., Blench, G., Gregson, M., Spedding, T., Soden, R. & Livingston, K. (2006) Developing oral communication and productive thinking skills in HM prisons. London: Learning and Skills Research Centre. Snow, P.C. & Powell, M.B. (2005) What's the story? An exploration of narrative language abilities in male juvenile offenders, Psychology, Crime and Law 11(3), pp.239-253. Snow, P.C. & Powell, M.B. (2008) Oral language competence, social skills, and high risk boys: What are juvenile offenders trying to tell us?, Children and Society 22, pp.16-28. Wales Justice Coalition (2010) Locked Up and Locked Out Communication is the Key. Available at: http:// (Accessed: 26 April 2011). Resources Howard League of Penal Reform, see www. Royal College of Speech and Language Therapists Criminal Justice Campaign, campaigns/Criminal_justice_campaign_briefing

How has this article changed your thinking? Let us know - see information about Speech & Language Therapy in Practices Critical Friends at

Dr Rachel Iredale JP (email is a Reader in the Faculty of Health, Sport and Science and Dr Harriet Pierpoint a Reader in the Faculty of Humanities and Social Sciences at the University of Glamorgan. Beth Parow is a speech and language therapist with Cardiff and Vale University Health Board.




One lucky contributor in each issue receives 50 in vouchers from Speechmark (, which publishes a wide range of practical resources for health and education professionals.

In Brief...

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Editors choice

Accent on aphasia
Caroline Newton and Carolyn Bruce draw attention to the practical implications of research which suggests that an unfamiliar accent can have a subtle but significant effect on comprehension in people with aphasia, and possibly other communication difficulties too. ne consequence of the rise in immigration and internal migration in the UK in recent years is that listeners frequently encounter speakers with different accents. In the NHS a culturallydiverse health workforce is beneficial in many ways, not least in providing a shared language and background for the range of patients receiving care; but there may be challenges too. Research amongst adults with no communication or cognitive difficulties has shown that an unfamiliar accent has a detrimental effect on comprehension, and that listeners have greater difficulty with foreign accents than with regional accents (Adank et al., 2009). A similar pattern of difficulty has been observed in adults with aphasia (Dunton et al., 2011). If such an individual has difficulty understanding someone with a different accent, this may have significant implications for their rehabilitation and participation in the community. This study involved 12 adults with chronic aphasia, due to a dominant hemisphere stroke, with an average age of 60 years. The participants presented with a wide range of communication difficulties and levels of severity. We asked them to listen to six narratives from the Discourse Comprehension Test (Brookshire & Nicholas, 1997) prior to answering eight yes-no questions for each story. Three stories were presented in a standard accent familiar to all the listeners (Southern Standard British English), and three in an unfamiliar Glaswegian accent. The questions were presented in Southern Standard British English. We found no difference in participants overall performance on the task between the familiar and unfamiliar accents. This is unsurprising, given previous accent research with people with aphasia, where significant difficulties in comprehension tasks have only been observed for foreign accents. It is also possible that listeners linguistic and world knowledge and the context provided in the narratives aided comprehension in the task. However, we did observe an effect of accent in an analysis of the type of information required by the questions: the participants made significantly more errors on questions tapping implied information (which has to be inferred from other information in the narrative) than those drawing on stated information (which is given in the narrative) in the unfamiliar accent. No such difference was found for the narratives in the familiar accent. These findings pose challenges for speech and language therapists, and all those who work with people with aphasia. Although regional accents may not cause the same level of comprehension difficulty as a foreign accent, our research shows that problems with some unfamiliar accents may only become evident with increasing processing demands. For example, the increased demands of an unfamiliar accent combined with complex information may be particularly problematic for people with aphasia. There may also be implications for work with other client groups: for example, there is some evidence that children with speech difficulties (Nathan & Wells, 2001) as well as people with dementia (Mahendra et al., 1999) also have particular difficulty understanding information presented in an unfamiliar accent. Speech and language therapists therefore need to be aware of the possible impact that their own accent, as well as others, may have on the performance of clients and be able to make adjustments to clients assessment and management. Adjustments might include involving a familiar-accented speaker in the assessment process, using recorded materials that expose the client to a range of accents within the therapy sessions, and making a recording of therapy materials by a family member. Caroline Newton (email and Carolyn Bruce are lecturers at University College London.
References Adank, P., Evans, B., Stuart-Smith, J. & Scott, S.K. (2009) Comprehension of familiar and unfamiliar native accents under adverse listening conditions, Journal of Experimental Psychology: Human Perception and Performance 35, pp.520-529. Brookshire, R.H. & Nicholas, L.E. (1997) Discourse Comprehension Test (2nd edn.) New Mexico: PICA Programs. Dunton, J., Bruce, C. & Newton, C. (2011) Investigating the impact of unfamiliar speaker accent on auditory comprehension in adults with aphasia, International Journal of Language & Communication Disorders 46(1), pp.63-73. Mahendra, N., Bayles, K.A. & Tomoeda, C.K. (1999) Effect of an unfamiliar accent on the repetition ability of normal elders and individuals with Alzheimers disease, Journal of Medical SpeechLanguage Pathology 7, pp.223230. Nathan, L. & Wells, B. (2001) Can children with speech difficulties process an unfamiliar accent?, Applied Psycholinguistics 22, pp.343361.

So many journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.

In recent years we have become increasingly aware of laryngopharyngeal reflux, its influence on the voice and the available drug treatment to complement our intervention. Randhawa, Mansuri & Rubins Is dysphonia due to allergic laryngitis being misdiagnosed as laryngopharyngeal reflux? is a timely and well-constructed reminder to keep thinking critically to avoid clients receiving treatment that is inappropriate, ineffective and potentially harmful. The authors note the small sample size of 15 and plan to take their initial results to a full-scale study. As they say, The clinical applicability would be massive, as it would lead to a change in the trend of current practice (p.4). Logopedics Phoniatrics Vocology (2010) 35, pp.1-5 In Imitation therapy for non-verbal toddlers, Gill, Mehta, Fredenburg & Bartlett are to be commended for their patience in conducting a study that took 7 years to get a series of 5 participants, and spanned two editions of the Preschool Language Scale! Thorough information is included about the rationale for the therapy, how it was conducted and the results. These support the authors conclusion that the outcome was encouraging (p.104) and give sufficient detail to enable readers to consider using the approach. It was therefore a real shame to then be told that, Whether the participants in this study eventually produced normal language is unknown at this time (p.106). Child Language Teaching & Therapy (2011) 27(1), pp.97-108 Regular readers will know I am exercised by what can be problematic relationships between speech and language therapists and educational psychologists. I hope McConnellogues Professional roles and responsibilities in meeting the needs of children with speech, language and communication needs: joint working between educational psychologists and speech and language therapists will be read by our profession too. She argues for commissioning of protocols and procedures for interagency working, particularly the sharing of information (p.60), as Ultimately it was concerns about sharing information without prior consent...which prevented the development of a communication system between EPs and SLTs as a result of the current pilot study (p.61). Practical steps for individual professionals are also suggested. Educational Psychology in Practice (2011) 27(1), pp.53-64



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Journal club 4: intervention studies

Jennifer Reids series aims to help you access the speech and language therapy literature, assess its credibility and decide how to act on your findings. Each instalment takes the mystery out of critically appraising a different type of journal article. Here, she looks at intervention studies.


he intervention study tool we will explore here is suitable for appraising experimental studies which set out to measure outcomes from provision of a therapy (or other kind of intervention) whose purpose is to alleviate either a persons difficulties or their impact on the persons life. We have now covered several appraisal tools, so you may be feeling it is not always obvious which to choose. To help you sort out what a study is really about, and whether it refers to interventions, try to match its aim to one of these questions: 1. What can we observe in people who have a particular risk factor or condition? If the investigators did not provide an intervention themselves but were looking at outcomes in people who may have received one type of intervention or another, you are probably looking at an observational design. In observational studies, the researchers do not provide an intervention or otherwise seek to promote change in individuals. They examine aspects of peoples past and/or present life and seek to find factors that are associated with each other. Sometimes this may involve collecting data about the intervention(s) received. The underlying quest in observational studies is usually to identify factors which might be causally related (and thus may be incorporated into interventions to produce better outcomes in the future). We will come back to the appraisal of observational studies in a future Journal Club. 2. What can people tell us about their experience of living with a particular risk factor or condition? Does the study appear to be less about objective observation of outcomes and facts, and more about eliciting peoples subjective experiences of the impact of their condition or of being the recipient of interventions? You may find that the qualitative study appraisal tool in Journal Club 2 (Winter 2010) is most applicable. 3. Does a given therapy or intervention work? If a quick skim of the abstract and/or method of the article suggests that the author is simply describing an intervention (or range of interventions), it does not qualify as an intervention study. Instead, it may be appraised using the expert opinion tool in Journal Club 1 (Autumn 2010). If the authors are reviewing or combining the results of more than one published study, then the systematic review

tool in Journal Club 3 (Spring 2011) is more likely to be the one to use. Once you have ascertained that the study in question is indeed an intervention study, you then need to ask one further question to drill down to the right tool: 4. Does this study use a group design or a single-subject design? Did the researchers provide the intervention to one group of people and compare the group results with those of people who either received a different intervention or no intervention at all? If the answer is yes, you can use the intervention study tool in this article. If, on the other hand, the study is about one persons treatment results or a series of individuals in which there is no comparison group receiving a different or no treatment, then you are probably dealing with a single-subject design. An appraisal tool for single-subject design studies will follow in a subsequent Journal Club. Single-subject designs most often use multiple baselines to compare treated and untreated targets within a single individual, so look out for that terminology. The gold standard design for an intervention study is the randomised controlled trial (RCT). The framework in this article can also be used for other types of intervention study, such as exploratory, preliminary or pilot-study designs, but you need to use the separate tool for appraising reports of single-case study and case series designs. This is because group designs help minimise the opportunity for bias arising from the Hawthorne effect (people tend to behave or respond differently when they know they are participants in a study) and the placebo effect (people receiving treatment of any kind do better than those receiving no treatment). It is not possible to rule out these effects from research using single-subject designs. Group studies in which the data from individuals is pooled but there is no control (comparison) group can pretty much be avoided as inadequate. Since neither Hawthorne nor placebo effect are controlled, any treatment outcomes could be entirely non-specific. There is little point in demonstrating a change that could have resulted from any old intervention Pam

Enderbys description of early aphasia therapy research as trials of random niceness comes to mind again. One exception may be when research is at the pre-clinical or modelling phase of the development of a complex intervention, when you may be interested in the content of and theoretical justification for untested interventions (MRC, 2000). Having identified your intervention study, ask the following questions to appraise its quality. The issues are the ones that you will find in any of the published frameworks for appraisal of randomised controlled trials, such as Critical Appraisal Skills Programme (CASP) (PHRU, 2006) or the PEDro Scale (Physiotherapy Evidence Database, 1999). And if you want a good laugh (yes, really!) about why these issues are important, I recommend Ben Goldacres Bad Science (2009). Beware, though, as you may never feel the same way again about vitamin supplements, brain gym or homeopathy This appraisal starts the same way as for a systematic review (Journal Club 3, Spring 2011): Question 1: What question was being asked, and is this an important clinical question?

Try formulating the reviewers stated aims into a research question if they have not done so explicitly in the article. Is the question clearly focused in terms of the PICO framework: Population studied Intervention given Comparator/control(s) used Outcomes considered? Is this question important for your clinical practice? If the reviewers question does not quite fit the bill, what question(s) do you wish they had asked instead? (The study may provide a partial answer.)



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Question 2: Was this a randomised controlled trial (RCT) and, if so, was it appropriately so?
Figure 1 Constraint Induced Language Therapy (CILT) A set of interventions referred to as constraint induced therapy (CIT) has been described that applies principles of use-dependent learning. Constraint Induced Movement Therapy (CIMT) is based on the notion that the potential rehabilitation of the affected limb is detrimentally influenced by the compensatory use of the unaffected limb, through a process of learned nonuse Investigations of CIMT in chronic stroke have suggested substantial increases in the amount and quality of movement which translated to real-world improvements in use of the affected limb The key principles of CIMT include (1) massed practice occurring in an enriched environment, (2) constraint of the unaffected limb during all waking hours using a sling, and (3) forced use of the affected limb Recently, Pulvermller et al. (2001) incorporated these core features of use-dependent learning in the context of language. They studied 17 inpatients with chronic aphasia who had received prior language therapy and were believed to have exhausted their recovery potential. Ten subjects participated in small group therapeutic activity intensively for three hours per day over a two-week period. this preliminary study showed significant improvement for the experimental group in the amount and quality of communication. (Maher et al., 2006, p.844)

Do the authors discuss why this study was carried out, either as a randomised controlled trial or otherwise? Most of the interventions of interest to speech and language therapists are complex interventions. Medical Research Council guidelines define these as ones which, whether therapeutic or preventative, comprise a number of separate elements which seem essential to the proper functioning of the intervention although the active ingredient of the intervention that is effective is difficult to specify. If we were to consider a randomised controlled trial of a drug vs. a placebo as being at the simplest end of the spectrum, then we might see a comparison of a stroke unit to traditional care as being at the most complex end of the spectrum. The greater the difficulty in defining precisely what, exactly, are the active ingredients of an intervention and how they relate to each other, the greater the likelihood that you are dealing with a complex intervention. (MRC, 2000, p.1) Just because the randomised controlled trial design is the gold standard for interventions does not mean researchers can or should be undertaking a randomised controlled trial of a complex intervention before the preliminary work has been done to establish an adequate description of its components: Complex interventions are built up from a number of components, which may act both independently and inter-dependently. The components usually include behaviours, parameters of behaviours (e.g. frequency, timing), and methods of organising and delivering those behaviours (e.g. type(s) of practitioner, setting and location). It is not easy precisely to define the active ingredients of a complex intervention. For example, although research suggests that stroke units work, what, exactly, is a stroke unit? What are the active ingredients that make it work? The physical set-up? The mix of care providers? The skills of the providers? The technologies available? The organisational arrangements? (MRC, 2000, p.2) So you need to ask at what stage of development this intervention is and, therefore, whether a randomised controlled trial at this stage is appropriate. In one of our local journal clubs, we reviewed an article on Constraint Induced Language Therapy (CILT) for people with aphasia (Maher et al., 2006) (figure 1). We thought their question was something like, Does Constraint Induced Language Therapy change the spoken

Figure 2 Enough jargon to sink that little pilot boat... Prospective means looking forward so its trying to answer the question, What will happen if we do x? rather than, What happened to these people in the past? (retrospective). Its use here seems a bit redundant since this is an intervention rather than an observational study. Repeated measures means you use the same tools to measure participants skills, behaviours etc. at pre-set intervals of time before, sometimes during, and after the treatment. This is one of the methods usually associated with a single-case study or case series design. This study used a mixture of standardised measures such as the Western Aphasia Battery and Boston Naming Test, and narrative analysis of a retelling of the Cinderella story, but no measures to detect more functional gains. Pilot study is using the analogy of the pilot boat which leads the way for a larger, less manoeuvrable (but more powerful) ship. Describing it as a pilot study also releases the authors from some of the constraints of the randomised controlled trial, allowing them to get a study into print that would otherwise fall foul of peer reviewers criticisms.

language behaviour of people with chronic, stroke-induced aphasia (with or without dyspraxia) compared to a similar dosage of multi-modal PACE (Promoting Aphasics Communicative Effectiveness)-type therapy? Maybe not the question we would have chosen to ask but still potentially of interest. The design was described by the authors as a prospective, repeated measures pilot study (figure 2). Not a randomised controlled trial then, but probably an appropriate design for early studies of a new therapy. Question 3: Were participants appropriately allocated to intervention and control groups?

Was the method of allocation adequately described and truly random? Each participant should have had an equal chance of being allocated to any of the study groups. It might seem a bit pedantic, putting in all that detail of sealed envelopes and independent personnel, but there is a reason for it. The whole purpose of a group study is to test whether the intervention effect you are interested in occurs when the intervention is provided for a particular

population of people with communication or swallowing difficulties. Randomisation ensures that groups are sufficiently similar to wipe out any differences in results that might occur because of individual differences. Have you ever read the results of a group study and been frustrated at the lack of detail about its impact on individuals? Well, thats exactly the point. The group study should tell you about the strength of the interventions effect irrespective of individual differences, so the study method needs to control for possible interference from inadequate randomisation. There is a large accumulation of evidence that people are influenced by knowledge of study participants and so (even if only subconsciously) may allocate to treatment rather than control groups participants who are, for example, keener, more worthy, more likely to adhere to the treatment schedule Hence the need for distance, independence and no personal contact with the participants. Researchers may use stratification to ensure equal or balanced numbers of certain types of participant such as boys and girls, or people living in three different parts of the country, or people with different levels of severity of a condition. Randomisation then takes place within each stratification group. Were the groups well balanced? Look for tables or other data describing potentially important characteristics of the study groups, and evidence that the authors have checked (with statistical tests if appropriate) that the groups are indeed similar enough to control for




individual differences between participants. Sometimes, despite adequate randomisation, differences between study groups occur. If these are reported you need to ask whether they could confound the study results that is, whether the differences might account for some of the observed outcomes. In Maher et al. (2006), allocation was not random but the procedure and the characteristics of the resulting groups were well enough described. We had concerns about the very small number of participants (9), and that differences between the groups might have introduced some bias (for example, the wider age range in the PACE group; client communication preferences; presence or absence of dyspraxia). Question 4: Were participants, staff and study personnel blind to participants study group? Question 5: Can the results be applied to the local population? investigators do all the work and then are unable to demonstrate convincingly that the intervention had an effect over and above what it was being compared to. They may find that the difference between the outcomes of the different interventions was not statistically significant. It does not necessarily mean there is no effect, but you end up not knowing whether the intervention was ineffective or whether the design of the study was just not powerful enough to capture it. So no further on. This is another reason for doing adequate pre-trial pilot studies, as their results can help provide the basis for the estimates of effect size needed to do a power calculation. We felt the Maher et al. (2006) participants, recruited through advertising and having received unknown amounts of previous therapy, would probably be representative only of our younger, relatively independent and highly motivated clients. Question7: Is the intervention described in sufficient detail?

As in other appraisal frameworks you need to examine the detail to determine whether there are important differences between the population sampled for the research study and the population of your own context. It may also be useful to consider practical aspects, such as could you provide the same intervention in your setting? Evidence-based practice is often modelled as a triangle with its three components being best research evidence + expertise of the practitioner + client preference. As the impact on clinical decision-making of resources and service delivery options arising from the local context cannot be ignored, some authors include these constraints as a fourth component of evidence-based practice. Question 6: Was the selection and follow-up of the participants adequate?

Blinding is about minimising the potential for observer bias, specifically the tendency for assessors to expect more change amongst individuals in treatment than control groups. The existence of this effect, like the placebo, is very well substantiated in the medical and psychological literature, so the need for blinding is an important aspect of good research design. However, there are limitations on where and how much speech and language therapy treatment studies can employ blinding. In a single blind study, the participants do not know which group they are in, while in a double blind study, neither do the investigators. In speech and language therapy research, it is very unlikely that participants and practitioners can be blind to participants group, so it is good practice for other people to undertake the assessments and outcome measures. A bit of common sense can help. Did they employ blinding wherever it was possible to do so? If blinding was missing from some measures, does it really matter for this study? No information was given in Maher et al. (2006) on who administered the standardised measures, but the narrative sample analysis was done blind to both treatment group and whether pre-, post- or 1 month after treatment status. It seemed to us much more important that blinding was applied to these measures, so we were less concerned about the potential for observer bias from possible lack of blinding in the standardised tests.

Were there any differences in data collection that might introduce performance bias? For example, were there any differences between the groups in the time intervals between measures? Did assessments undertaken by participants differ so that one group received a lot more attention from researchers, therapists or other practitioners? Did the study have enough participants to minimise the play of chance? Look for a report of a power calculation if this is a fullscale randomised controlled trial. Power calculations estimate how many participants are needed to be reasonably sure of finding out whether an intervention really does have a specific effect. If you cant handle the stats, at least check that the authors have considered the possibility of having too few participants. The danger of this is that the

Could you replicate the intervention on the basis of the information given? Look back to the earlier quote from the Medical Research Council Guidelines. The authors should have provided a thorough description of the intervention with reference to components such as: intensity (eg. frequency and length of sessions) dosage (eg. how many hours of therapy over what length of time) scheduling (eg. distributed learning or massed practice) content (eg. targets, success criteria, resources) role/responses of therapist or other practitioner (how changes in behaviour are facilitated eg. modelling, contingent responses, scaffolding, recasting) methods used to minimise systematic differences between practitioners delivering the interventions (eg. manualising the intervention, training the practitioners, measuring fidelity). The authors should provide information on the track record of the intervention, if it has one, with a summary of the current evidence for its efficacy (delivery under ideal conditions) or effectiveness (delivery in real world settings). For innovative interventions, ask whether they are founded on sound theoretical and practice-based principles.

Critical appraisal for speech and language therapists (CASLT) Download the intervention study framework document from for use by yourself or with colleagues in a journal club.


The two core components of Constraint Induced Language Therapy (CILT) are (a) massed practice and (b) forced use of speech. Maher et al. (2006) wanted to see whether (b) still produced better results if the intensity was controlled. They delivered therapy in dyads or triads using a dual card request-and-respond task (collecting pairs) with several levels of difficulty (semantic and syntactic). The PACE group could use any modality while the CILT group had to use speech. Cuing and shaping strategy were used by therapists with the CILT group only. Although their conceptualisation of the interventions felt quite narrow, both the CILT and PACE-type interventions were well enough described for us to be confident we could replicate them (although we did wonder how we would fill 3 hours a day doing the card game activities they described without losing the plot!) Question 8: Were all of the participants who entered the trial accounted for at its conclusion? You need to consider: whether the authors interpretation of numbers was sensible, how the results are expressed (eg. proportion of participants with a given outcome, or as a measurement such as mean or median differences?) how large and how meaningful this size of result is get some more practice in looking at p-values and confidence intervals without that blink and miss reaction! Try to sum up the bottom-line result of the study in one sentence this also helps you communicate the gist of your appraisal to others. For Maher et al. (2006), standardised measures suggested positive post-treatment changes in both groups. Results from the narrative measures were more equivocal, although the authors argued for the existence of a trend towards better outcomes for the Constraint Induced Language Therapy group. Interpretation was also affected by incomplete follow-up data. We concluded that the study was not powerful enough (too few participants) and had too many potential confounding factors (sources of bias) to detect any reliable difference in the effect of the two interventions. Question 10: Were all important outcomes considered so the results can be applied to practice? Attrition in this context is about how many participants were lost from the study before outcomes were measured. Authors should report this clearly and, if necessary, show how they took account of this in their results. You would have cause to worry about the study results if attrition was high and/or unequal across groups. How did the investigators handle the situation of participants wishing to move to a different group? Such moves challenge the integrity of randomisation and may compromise the study results. The solution, however counter-intuitive, is to analyse participants outcomes by the groups to which they were originally allocated. This is called intention-to-treat analysis. It is one of the core standards used internationally in randomised controlled trial quality appraisal schemes, so it is good to know this bit of jargon. One of the participants in Maher et al. (2006) allocated to the PACE group refused to use any modality other than speech. However, his results were retained and analysed within his allocated group. We can give them a point for intention-to-treat analysis even though this was not a randomised controlled trial. Question 9: What are the main results, and how are they presented? How results are expressed can have an important influence on what you perceive as the main result. thought we would need to be very sure about our selection criteria before offering Constraint Induced Language Therapy as an option for a particular client. Question 11: Should policy or practice change as a result of the evidence in this review? Consider whether any benefit reported outweighs any harm and/or cost. If this information is not reported, can you fill it in from elsewhere? You should adopt a broad view of harm here it does not just mean physical harm such as from swallowing difficulties. When people undertake an intervention, this prevents them from doing something else, and it sets up expectations that may be disappointed. How could expectations be managed in your local context? Could you provide equal or fair access to a new intervention? Does your service provide clients with information on intervention alternatives and support them to be involved in decision-making? These are important issues to consider before adopting a new or alternative intervention. Consider cost, too, not just from the perspective of the service. Intensive therapy may be a real challenge for many clients and families because of its costs in time and lost employment. You should conclude with a judgement about whether there is sufficient weight of evidence to justify implementing changes to policy or practice in your service. There was not enough evidence in Maher et al. (2006) alone to make a decision about whether Constraint Induced Language Therapy should be accessible across Fife, but we agreed we needed to look at the broader evidence base. Certainly, as described in the study, it lacked clinical feasibility for us. We need to see results from studies in which intensity and content are varied as well as studies using populations that SLTP more reflect our clients. Jennifer Reid is a consultant speech and language therapist with NHS Fife, email Cartoons are by Fran,
References Goldacre, B. (2009) Bad Science. London: Harper Perennial. Maher, L.M., Kendall, D., Swearengin, J.A., Rodriguez, A., Leon, S.A., Pingel, K., Holland, A. & Gonzalez Rothi, L.J. (2006) A pilot study of use-dependent learning in the context of Constraint Induced Language Therapy, Journal of the International Neuropsychological Society 12, pp.843-852. Medical Research Council (2000) Guidelines on the development and evaluation of RCTs for complex interventions. Available at: Utilities/Documentrecord/index.htm?d=MRC003372 (Accessed: 5 May 2011). Physiotherapy Evidence Database (1999) PEDro Scale. Available at: downloads/pedro-scale/ (Accessed: 5 May 2011). Public Health Research Unit (2006) Critical Appraisal Skills Programme. Available at: http://www.phru.nhs. uk/Pages/PHD/CASP.htm (Accessed: 5 May 2011).

Could the people included in the study be different from your population in ways that would produce different results? Does your local setting differ much from that of the trial? Could you provide the same treatment in your setting, given local constraints and opportunities? If not, what changes would be needed to your services resources or to their deployment? Consider outcomes from different points of view including that of the client and family, the wider community, professionals and policy makers. These were our comments on Maher et al. (2006): We remain unconvinced about how replicable this conceptualisation of Constraint Induced Language Therapy would be in our settings getting well-matched dyads or triads would be difficult in most settings. How would you do this, for example, with someone in a care home? We thought there might be potential for delivering massed practice intensity via telemedicine or computer, although this would need a different core of therapy tasks. We worried how you would retrieve a negative outcome from using Constraint Induced Language Therapy with a client in order to get back to a total communication approach. We




Read to succeed
Kate Wright explains how a collaborative project with a childrens centre and the library service has had an impact on the quality of routine book sharing and associated language stimulation with preschool children in an area of deprivation.
ensington and Chelsea is an interesting area demographically, with extremes of wealth and deprivation. It is the most densely populated local authority in the UK. Using the Indices of Multiple Deprivation, the 10 per cent most deprived in the borough are also within the top 10 per cent of the most deprived areas in the UK. The Bercow Report (2008) highlighted that, in areas of social disadvantage, as many as 40-50 per cent of children at school entry have transient language or communication difficulties. However, with the right support and good quality preschool environments, we can compensate for this. This is the aim of Kensington and Chelseas community early years service to nurseries. As a team we work with childrens centres to support nursery staff in creating a language-rich learning environment (Falkus, 2003). This is achieved through regular visits, working with identified staff to develop their skills in recognising and supporting children with speech, language and communication needs. We also offer two day interactive training courses covering typical speech and language development, bilingualism, discussing concerns with parents, and how and when to refer. Books are a great way to develop language and learning. Schoon et al. (2010) conducted a longitudinal study looking at the early influences on language development, and found that exposure to a stimulating literacy environment early in life had a positive impact on receptive language skills of the children. However, speech and language therapists in our service had noticed that, in some early years settings, books were not used interactively or included in weekly planning, and sometimes not regularly used at all. Whitehurst & Lonigan (2001) found that some children enter school with fewer than 25 hours shared book reading. This is pitifully little, averaging just over 6 hours a year - or 7 minutes a week - in their first 4 years. Dickinson & Tabors (2001) also found that teachers of children aged 3 and 4 read with children on average less than 8 minutes per day. Only 4 per cent of teachers read for more than 20 minutes. However, Wasik & Bond (2001) found that, when teachers are trained in using books and extension activities to teach vocabulary in a preschool classroom setting, they can


Kate Wright

increase the vocabulary development of 4 year olds from low-income families attending an early learning centre. As a team we felt there was both a fundamental need and a great opportunity to tackle the issues around book reading in the borough, establish some joint working, and further develop our service. In 2008 our service delivery model offered nursery settings three options: 1. Language Groups supporting staff to run small language groups with children at risk of language delay 2. Practitioners as Play Partners supporting staff to develop their adult-child interaction skills through video feedback 3. Enhancing Circle and Story Times supporting staff to develop childrens language skills through circle and story time sessions. In 2009 we extended the Enhancing Circle and Story Time strand, incorporating current research and best practice and working with parents and carers as well as practitioners. Crucial to the success of the project was the involvement of the Kensington and Chelsea

Library Services. They provided extra books and timed the distribution of Bookstart packs with the workshops we delivered. (Bookstart is a national programme that provides young children and their families across the UK with free packs of books and tips and ideas for parents on how to enjoy sharing books together.) We asked a childrens centre in an area of the local borough with the highest level of deprivation to pilot our programme. Children from such a background are more at risk of language development issues (Locke et al., 2002) and benefit particularly from a good quality preschool experience (Sylva et al., 2004). 1. Working with parents and carers Parental involvement was a key aim, because research has shown that frequency of parentchild reading in the home can enhance preschool childrens language skills and contribute to gains in their vocabulary, oral language complexity and narrative skills (Zevenbergen & Whitehurst, 2003). We offered two parent workshops in the childrens centre, lasting an hour each. They were timed to begin when the children are dropped off.



from all parents who attended either workshop. These included: This workshop has shown me quite a bit. I will read more and help my son to learn. I will spend more time reading with my child. I will make my story time interactive, and at different times of the day. I will follow my childs lead. I will turn book reading into role play. 2. Working with practitioners Prior to the implementation of Read to Succeed, we attended a staff meeting at the childrens centre to introduce the project. From this we agreed on three named practitioners to work closely with the speech and language therapist and receive weekly support for the pilot project. We then arranged a half-day inservice training for all staff, which included: a. Research demonstrating the effectiveness of using shared book reading to develop childrens language skills b. Strategies to support language learning through shared book reading, including highlighting use of existing skills c. Involving parents and sharing information with them about the focus book. To achieve our aim of transferring ideas, learning, storytelling and vocabulary from the book into the whole learning environment, it was important to discuss how the story time sessions could be put into practice and how practitioners could manage story times in small groups. As a group the practitioners devised a timetable which meant that each practitioner would run at least one small group story time session a week. They also ensured that each child would be involved in at least one story time session per week. They displayed and used a tick-sheet to keep track of whether the session ran and which children were involved. This also meant that parents were aware of whether their child had participated in a story time session and the book that was used. The speech and language therapy team provided half-day weekly visits for six weeks. We supported the identified practitioners to run story time sessions for small groups of children and plan carryover activities such as porridge tasting for Goldilocks. To make the sessions successful we also had 15 minutes of additional time spent with the practitioner alone. This enabled us to discuss strategies and the effect on the children, and also plan for the following week. Overall the structure of the input worked to the schedule in figure 2. There were two strands to the evaluation of our work with practitioners. Firstly, we gave them all a questionnaire on the time spent reading each week to the children, for how long, and with how many different books. We repeated this six weeks later, after the speech and language therapy visits. The pre-workshop questionnaire showed that all the practitioners were already reading between one and three times a week with their group. Although there was no marked change, each of the practitioners increased

Completion prompts - leave a gap at the end of a sentence, eg. I wrote to the zoo and they sent me a Recall prompts - questions about what happened in a book a child has already read, eg. Do you remember what the giraffe did with the tie? Open-ended prompts these encourage children to give longer responses and often focus on pictures in the books, eg. tell me whats happening in this picture Wh- prompts - usually begin with what, where, when, why, and how, eg. I wonder why the fox is sad? Distancing prompts - relates the pictures or words in books to experiences outside the book, eg. who do we know that could help us put the fire out? Figure 1 Strategies (CROWD Prompts) from dialogic reading (Whitehurst, 1992) Week 1 Weeks 2-5 Week 6 Speech and language therapist to demonstrate story times / language group using strategies discussed in training Introduce props Discuss carry-over activities and target for the week Speech and language therapist and practitioner agree action plan of story time / language group sessions who/what/how/when Speech and language therapist to observe practitioner running story time with new book using the Story Time Observation Record

Figure 2 Schedule

The first workshop focused on the value of shared book reading in supporting the development of language and thinking skills, as well as introducing general interaction strategies. Attendance was high (7 mothers and 1 father). It was interesting that these parents were all already reading 4-5 times a week with their child. We introduced specific strategies (figure 1) from dialogic reading (Whitehurst, 1992). Dialogic reading is based upon three main techniques - asking what questions, asking open-ended questions and expanding upon what the child says. In addition we gave the parents techniques for when their child needed simplification, for example using forced alternatives (is it a fireman or a vet?) to help their child respond to a question they had difficulty answering. We aimed for parents to take away the idea that they can turn book reading into a conversation. A vital section of the workshops was overcoming barriers to book reading. The childrens centre caters for children from a nearby Traveller community site, and Traveller communities are historically known to have literacy difficulties (Levinson, 2007). In addition, 45 per cent of the children who attend the childrens centre have English as an additional language. We included these families in our planning, as we hoped they would attend and felt they would benefit greatly from the input. The particular message we wanted to convey was that they didnt have to read the words in the book, but could instead make a story up using the pictures. It was more important that they made some time for book sharing and used the strategies we had discussed. We were really pleased that 75 per cent of the parents who attended had English as an additional language. (Unfortunately none of the parents

from the Traveller community attended, and I subsequently started going to the Traveller site to attempt to implement the programme.) Each parent in the childrens centre was given a Bookstart pack for their child, with a copy of the book that the practitioners would be reading in the childrens centre with all children over the next two weeks. One of the key aims was for parents to be reading the same book as the practitioners, thus ensuring maximum impact on childrens language development. Whitehurst & Lonigan (2001) found that the impact on childrens language is nearly doubled when parents are reading the same book at home that is being read in the nursery. The second session, two weeks after the first, gave parents the opportunity to discuss what differences they had noticed while reading with their child. Unfortunately we had a low uptake for this, with only two parents attending. We felt this may be due to the session running in the middle of August, with many families away. Questionnaires were given to parents at the beginning of the first workshop on how many different books they had read over the week, and how long they spent reading each time. This was then repeated at the end of the second workshop. The parents who attended the first workshop, but were unable to attend the second, were also sent the questionnaire to complete, and encouraged to return it by their childs keyworker. Unsurprisingly, given the book sharing that was already happening at home, there was no noticeable change in the amount postworkshop. We did, however, note qualitative changes. The evaluation asked what they would take away from the project and we found they had taken on board different, and valuable, ideas. Responses were gathered



the amount of times they read with the group, and there was some increase in the number who read the same book multiple times. For the second part of the evaluation, we looked at the effect on the three identified practitioners interaction skills and dialogic reading. Our informal observation form included 33 different interaction / reading strategies and activities, which we selected by looking at known language development strategies, and through best practice identified in research (Wasik & Bond, 2001; Whitehurst, 1992). The Story Time Observation Record form is available in the members area of For each strategy or activity, we observed whether the participants used it, sometimes used it, or never used it. We observed them pre-workshop, then again six weeks later at the end of the weekly visits. The most noticeable changes from the project were in the results for the three identified practitioners. They each showed considerable improvement in interaction, dialogic reading strategies and activities to extend the stories (figure 3). Each of the practitioners we worked with reported that they enjoyed Read to Succeed and as a staff team have elected to continue with the programme in preference to other service delivery options. One practitioner reported, I am more confident now. I know it is just about getting as much out of the book as possible. It all comes quite naturally now, I dont even realise I am using the strategies. Since the implementation of Read to Succeed the speech and language therapy team has noticed huge changes. The staff are now: 1. including small story group time in their weekly planning 2. creating book packs including props 3. independently planning, preparing and running story book times at least three times a week with follow-up extension activities. The staff team has also reported positive effects on the children since Read to Succeed: Since we have been doing the groups [name of child] and [name of child] are talking more. They say some of the words in the book and make the actions. I think its been good for the children. Theyre coming out with all the words in the books we have focused on. Its getting them to speak more. If the books are out they will pick them up and tell their own stories to each other because they are so familiar with them. We feel that the success of this project is due to multidisciplinary collaborative working and the realisation on the part of the practitioners that book sharing can easily fit into a daily routine and that it makes a great difference to the language skills of the SLTP children in their care. At the time of writing, Kate Wright was a speech and language therapist with Kensington and Chelsea PCT, Central London Community Healthcare, email
Used Pre Practitioner 1 Practitioner 2 Practitioner 3 35% 29% 26% Post 53% 59% 74% Sometimes used Pre 12% 12% 18% Post 3% 6% 6% Never used Pre 53% 56% 56% Post 39% 29% 12%

Figure 3 Percentage of total strategies / activities observed

Sandra, a member of staff at the childrens centre, gets into character

References Bercow, J. (2008) The Bercow Report. Available at: publicationdetail/page1/DCSF-00632-2008 (Accessed: 18 March 2011). Dickinson, D. K., & Tabors, P. O. (2001) Beginning literacy with language: Young children learning at home and school. Baltimore: Brookes. Falkus, G. (2003) Working with the whole nursery, Bulletin of the Royal College of Speech & Language Therapists 609, pp.5-6. Levinson, M.P. (2007) Literacy in English Gypsy Communities: Cultural Capital Manifested as Negative Assets, American Educational Research Journal 44(1), pp.5-39. Locke, A., Ginsborg, J. & Peers, I. (2002) Development and disadvantage: implications for the early years and beyond, International Journal of Language and Communication Disorders 37(1), pp.3-15. Schoon, I., Parsons, S., Rush, R. & Law, J. (2010) Childhood Language Skills and Adult Literacy: A 29-Year Follow-up Study, Pediatrics 125(3), pp.e459-e466. Sylva, K., Melhuish, E., Sammons, P., Siraj-Blatchford, I. & Taggart, B. (2004) Effective provision of pre-school education (EPPE) project: Final Report. London: The Institute of Education. Available at: http://education. Page1/SSU/FR/2004/01 (Accessed: 18 March 2011). Wasik, B.A. & Bond, M.A. (2001) Beyond the Pages of a Book: Interactive Book Reading and Language Development in Preschool Classrooms, Journal of Educational Psychology, 93(2), pp.243-250. Whitehurst, G.J. (1992) Dialogic Reading: An Effective Way to Read to Preschoolers. Available at: http://www. (Accessed: 18 March 2011). Whitehurst, G.J., & Lonigan, C.J. (2001) Emergent Literacy: Development from Prereaders to Readers, in Neuman, S.B. & Dickinson, D.K. (eds.) Handbook of Early Literacy Research. New York: The Guilford Press, pp.11-29.

Zevenbergen, A.A. & Whitehurst G.J. (2003) Dialogic reading: A shared picture book reading intervention for preschoolers, in van Kleeck, A., Stahl, S.A. & Bauer, E.B. (eds.) On reading books to children: Parents and Teachers. New Jersey: Lawrence Earlbaum Associates, pp.170-194. Resource Bookstart,

To comment on the difference this article has made to you, see guidance for Speech & Language Therapy in Practices Critical Friends at



boundary issues (5)

(Over)extended roles
Linda Armstrong considers the following scenario:
peech and language therapy has never been static. An examination of preCollege of Speech Therapists journals showed our earliest evidence-base focused on dysfluency and cleft lip and palate (Armstrong & Stansfield, 1996). The proportion of these disorders in our overall caseload has faded, and they have become specialities. Since 1984 when I graduated, different disorders and client groups have come into vogue according to medical and social priorities, such as people with learning disability, or geriatrics. The two main tidal waves of new areas of practice have been adult acquired dysphagia (with instrumental methods of assessment) and autistic spectrum disorders. These have been accompanied by the professional requirement for us to deliver evidence-based practice, an increase in the number of speech and language therapists, increased public awareness through the internet, and more challenge from clients and families when services fall short. Demand continues to outstrip supply as we aim to meet standards and follow guidelines, and this pattern is likely to mushroom in current economic and political conditions. Practice innovations and role evolution will likely increasingly have to happen without any new money. This will have a knock-on negative impact on current clients for whom less clinical time will be available. Arguably, the Health Professions Councils first and overarching - registrants duty will be contravened: You must act in the best interests of service users (HPC, 2008, p.3). Another relevant duty to this discussion is You must keep within your scope of practice (HPC, 2008, p.11). However, the Council also requires that therapists be able to change their practice as needed to take account of new developments (HPC, 2007, p.10). Though we are autonomous, the decisions we make about planning and delivering new services should sit within our scope of practice, and service and employer priorities. In this scenario, we have what Roulstone (2009, p.156) labels Reductions in one service to develop another: robbing Peter to pay Paul. We have tried hard over the years not to spread the jam thinner but to argue that we need to spend more rather than less time with individual clients to effect a change in their communication and/or swallowing. Frameworks such as Malcolmesss care aims ( have provided tools to measure the input required to reduce the impact of a clients communication

You are one of 3.5 whole time equivalents working with adults with acquired neurological, voice and fluency disorders. A full-time member of the team has been evolving a new role. There is no new money, and no benefit to the teams usual clients. Where before you had the flexibility to adapt and innovate, you are now struggling to provide them with an evidence based service.
BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics (2008) require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this series we think through everyday events which receive much less attention but also need to be on our ethical radar. and/or swallowing disorder. Squeezing a new role into a service probably already under-resourced cannot facilitate a clinically effective service for our existing clients or those covered by the new role. Our professional body was concerned enough about new and evolving roles to produce a policy statement (RCSLT, 2008). Its examples are mainly for medical, hospitalbased (invasive) procedures, which seem to predominate in current evolving roles. Other new roles for an adult service might involve advocacy for clients, or work in conjunction with job centres to support people back to work. We are cautioned that a new role should not be developed because it saves someone else from doing a job for which they are trained but consider the activity to be a low priority (p.5). So we should ask ourselves whether a speech and language therapist is necessary to fulfil the proposed new role. The policy statement provides a flow chart to support us in decision-making (p.7) and so focuses on the processes and safeguards necessary to establish new practices (p.3). Funding and resources are considered to be local management issues (p.3). Thus, in this scenario, it is the managers responsibility to agree a new role before it is assumed, and to assess how it fits within current service provision and financial limitations. This might be achieved by measuring increased waiting times for current client groups, or reduced frequency of sessions with current clients. Alternatively, part of the existing service may have to be withdrawn, or devolved to our support workers, other professionals or lay carers. Speech and language therapy is a constantly evolving profession for which

Linda Armstrong (pictured on holiday with her husband) is a speech and language therapist with NHS Tayside in Perth & Kinross (email

new roles are developed to fit with changing needs and emerging evidence (RCSLT, 2008, p.3). Ilsley (2011) and Haines (2011) discuss new roles related to people with chronic obstructive pulmonary disease and other respiratory conditions. The professions early members would hardly recognise much of our work now. In this scenario, perhaps the new role will eventually complement and improve the service already provided. It may on the other hand continue to have a negative impact on core practice. It may even, over time, be instrumental in changing core practice and adding to our evidence-base. My concern remains that new roles without new resources inevitably have a detrimental effect on the service we provide to clients for whom we have an existing evidence base that suggests speech and language therapy can SLTP be effective and beneficial.
References Armstrong, L. & Stansfield, J. (1996) A Content Analysis of Speech, the Professional Journal of the British Society of Speech Therapists - the First Ten Years. Spotlight on Speech, 1935-1945, European Journal of Disorders of Communication 31, pp.91-105. Haines, J. (2011) Respiratory Speech and Language Therapy, RCSLT Bulletin 706, pp.15-16. Health Professions Council (2007) Standards of Proficiency. Available at: documents/10000529Standards_of_Proficiency_SLTs. pdf (Accessed 4 April 2011). Health Professions Council (2008) Standards of Conduct, Performance and Ethics. Available at: uly2008.pdf (Accessed 4 April 2011). Ilsley, E. (2011) Dysphagia and Chronic Obstructive Pulmonary Disease, RCSLT Bulletin 706, pp.13-14. Roulstone, S. (2009) Commentary on Scenario 8.2 in Body, R. & McAllister, L. (2009) Ethics in Speech and Language Therapy. Chichester: Wiley-Blackwell. Royal College of Speech & Language Therapists (2008) Policy Statement: Evolving Roles in Speech and Language Therapy. Available at: publications/RCSLT_Evolving_roles_Policy_Statement_ October_2008_a.pdf (Accessed 4 April 2011).




How I use the evidence in dysphagia management (1):

Prepared, proactive and preventative

Infants and children with complex needs have a range of difficulties with early feeding, eating and drinking. Celia Harding and colleagues demonstrate how an evidence-based problem solving framework can support community and developing specialist therapists to provide appropriate intervention.
Shyamani, a band 7 speech and language therapist, has received support and supervision from one of the authors since moving to a new post 12 months ago. She has a caseload of preschool children who have complex needs, and works within acute (neonatal unit and childrens ward) and community settings. Previously, she worked with children who have learning disabilities and a range of eating and drinking difficulties within preschool and school settings. Shyamani moved post to develop her dysphagia skills, particularly within the acute context. During reflective sessions she felt overwhelmed with the nature of some of the difficulties, particularly with infants. peech and language therapists within the field of complex needs work with infants, children and young people who have a range of difficulties with early feeding, eating and drinking. Increasingly, however, therapists who have community preschool caseloads are referred infants with complex needs on discharge from a neonatal unit. They may also be involved in assessing infants who develop feeding problems in the first few days or weeks of life. The therapist in community settings may be the first healthcare professional to engage intensively with parents and carers, in an area that has potentially long-term serious health consequences. Of concern for many is how to identify risk indicators - such as aspiration from ingested contents - in relation to general eating and drinking management. In this article, we seek to provide a problemsolving framework through discussion of appropriate intervention and ways to support clinical confidence and competence of junior staff (community generalists or developing specialists) working in paediatric dysphagia. Our reflections cover three key areas: understanding the caseload, parental stress and its impact, and appropriate support. 1. CASELOAD Most children on a paediatric dysphagia caseload will have some level of learning disability. People with learning disabilities have a higher prevalence of poor nutritional intake, which may be due to oral phase problems or more specific neurological difficulties with eating (Mathisen et al., 2002). Speech and language therapists are likely to spend time developing strategies and providing training to minimise risk, as persistent eating and drinking difficulties within the learning disabled population lead to poor health outcomes and reduced quality of life. Ultimately, if there is no clear identification of the problems, and strategies are not implemented consistently, then outcomes are serious for the health of the child. Dysphagia is therefore a significant health risk issue and requires appropriate case history taking, management and intervention to reduce the adverse effects (Harding & Wright, 2010; Hendrix, 1993). Unmet health screening and general health checks remain a major issue for the learning disabled population. Research for the Disability Rights Commission Formal Investigation (2006) into health inequalities found that people with learning disabilities of all ages have a higher level of respiratory disease and are more likely than other citizens to have significant health risks and major health problems. Key clinical areas include infants and children with neurological disorders such as cerebral palsy or, less frequently, acquired difficulties such as traumatic brain injury


Celia Harding

or brain tumours. Infants and children with developmental delay (including those with Down syndrome) and children within the autistic spectrum often present with feeding, eating and drinking difficulties. There are also likely to be children with gastrointestinal problems, in particular gastroesophageal reflux, as well as smaller groups who have renal disease, heart conditions and anatomical anomalies that impact on nutritional intake. Being aware of key aspects of what the difficulties are likely to be can enable a therapist to make a timely and appropriate management plan: a) Children with physical disabilities Research indicates that dysphagia increases with the degree of physical disability, and that



people who have severe learning disabilities and cerebral palsy have a higher level of eating and drinking difficulties and risk associated with dysphagia (cited in Harding & Wright, 2010). A survey in two health authorities in London suggests that children who have cerebral palsy are likely to have sucking (57 per cent) and swallowing (38 per cent) difficulties, and that 90 per cent have an oral difficulty that impairs eating and drinking skills (Reilly et al., 1996). Sullivan et al. (2000) surveyed 377 parents of children aged 4 to 18 years with neurological impairment, 367 of them having challenging mother-child interaction during mealtimes (Mathisen et al., 2002). d) Children with other medical conditions Cardiopulmonary conditions, renal disorders and anatomical anomalies such as cleft palate are likely to impact on management. Cardiac problems are often associated with tiring, and therefore risk, over the period spent feeding. Children with renal disorders often have reduced interest in food, and therefore are at risk of food aversions (Hofner et al., 2000). Field et al. (2003) found that children with anatomical problems were more likely to have oral motor difficulties at the oral preparatory and oral phase of eating and drinking, plus food and texture aversions. Some children post- pharyngeal flap surgery associated with cleft palate develop conditioned dysphagia, in which they learn to avoid swallowing due to discomfort (Di Scipio & Kaslon,1982). 2. STRESS Having a child with a specific diagnosis or a learning difficulty especially one with associated health, physical and communication problems - is likely to cause a family significant stress. Parents may find themselves in a situation they had not anticipated; trying to understand the nature of the difficulty exposed, getting to grips with a range of appointments and professionals, or grieving for the child they thought they would have. While the increased psychological stress is particularly for mothers, feeding difficulties also cause significant stress for fathers (Sloper & Turner, 1993). Parents may have specific difficulties interacting and engaging with the child, and other care aspects such as mealtimes may take up a considerable amount of time and effort. Consequently, it may be an additional challenge for parents to undertake goals suggested by healthcare and education professionals. Research that targets specific disabilities yields additional and important information about parents. Parents who care for a child with cerebral palsy mention that their quality of life is reduced, and that undertaking the additional care aspects for a child with a disability impacts on the family health and maintenance of social-emotional networks. Additionally, while feeding is an important time for closeness and communication, this is not always possible due to the nature of the childs eating and drinking needs. Maintaining a stable and predictable routine is a challenge, especially if there are other siblings in the family and, overall, parents talk of feeling disempowered (Davis et al., 2009; Hewetson & Singh, 2009; Sleigh, 2005). In Sloper et al. (1991), families of children with Down syndrome felt their coping strategies were challenged and family relationships were strained. Mothers were particularly concerned with the child developing behavioural problems, although these concerns were less with mothers who had some employment responsibilities. A childs social competence and behaviour problems have a correlation with parental levels of stress (Dyson, 2003). Mothers who have learning difficulties themselves are at high risk of depression from social isolation (Feldman et al., 2002). 3. SUPPORT Parents generally value support from healthcare clinicians (Hewetson & Singh, 2009; Hoddinott & Pill, 2000; Sleigh 2005). However, it is useful to reflect on how we present information and set goals with parents. Davis et al. (2009) conducted a qualitative study with 37 parents of children with cerebral palsy. Reduced quality of life, difficulties in maintaining social networks and the childs long-term needs were key aspects. Parents feel they have to be proactive in seeking services and, when there is a difficulty, help is not forthcoming. This suggests therapists need to be forward planning in their management and intervention. This can only be implemented by knowing the key clinical indicators of the client group. Other issues with healthcare clinicians include arranging appointments, the number of appointments, little help during a crisis, feeling that information is not readily available and feeling demoralized and angry after consultations with professionals (Sleigh, 2005). Some parents feel information was not given in a timely way, or that there was conflict between

The therapist in community settings may be the first healthcare professional to engage intensively with parents and carers.
a diagnosis of cerebral palsy. Feeding, eating and drinking difficulties were a pervasive issue for most of the sample; 31 per cent had had a chest infection in the previous year, 89 per cent were not independent eaters and required some level of help during mealtimes, and 56 per cent choked on food. Twenty per cent reported that mealtimes were stressful, and 28 per cent reported spending around three hours per day feeding. b) Children with developmental delay Few surveys have evaluated the eating and drinking needs of children with developmental delay, but some suggest up to 80 per cent may have some degree of feeding difficulty. Children with Down syndrome are at higher risk of hypotonia at birth (Quartino, 2006), which predisposes them to have feeding problems early on. Field et al. (2003) reported that children with Down syndrome had particular difficulties with oral motor delay. This delayed the introduction of a wider range of textures and had a later impact on texture tolerance, resulting in food aversions. Children with autistic spectrum disorder may have issues with tolerating textures or with food refusal, but fewer specific difficulties with pharyngeal incompetence (Field et al., 2003). c) Children with a history of prematurity Children born prematurely, or those with developmental delay with an early history of severe reflux, can have difficulties establishing successful feeding (Bhatia & Parish, 2009; Douglas, 2002). Infants who have Gastroesophageal Reflux Disease (GORD) are likely to have lower energy intake, a significant increase in food refusal behaviours, be difficult and more demanding feeders and have

...parents said that clinicians too often observed them feeding the child, then offered joint problem solving. They would prefer clinicians to show, inform and suggest.
professionals wanting to move on to another goal versus parents not feeling quite confident or ready to progress. Loss of skills or a feeling of having reduced parenting abilities is also a theme (Hewetson & Singh, 2009; Hoddinott & Pill, 2000; Sleigh 2005). Parents were specific in the type of support they wanted; in particular parents said that clinicians too often observed them feeding the child, then offered joint problem solving. They would prefer clinicians to show, inform and suggest. Demonstrating hands-on skills rather than simply advising was more helpful in terms of developing and maintaining their own skills (Hewetson & Singh, 2009). One overall and rather worrying theme in the literature is of parents feeling they were not listened to.



how i

Figure 1 Shyamani uses the framework in practice Suleiman, a first child, was a term baby but has not been putting on weight. He is now three weeks old. His parents brought him into the Childrens Ambulatory Care Unit concerned about his failure to thrive. He was admitted to the childrens ward for a short period of observation. The medical team passed a nasogastric tube to assist Suleiman with weight gain. They noted he has significant difficulty in finishing his feeds. He also appeared to have reduced tone impacting on lip seal and cheek stability. His mother bottle feeds him, and has commented that Suleiman appears to become tired very quickly. Staff observed that he began with a normal pattern of sucking, but this became erratic half way through feeds. Further investigations revealed that Suleiman has a heart condition in conjunction with reflux. Shyamani structured her problem solving into the three key areas: 1. Prognostic indicators Shyamani has thought about the areas that will inform goal setting. Firstly, she knows that heart and reflux difficulties impact on the suck-swallowbreathe cycle in infant feeding. Secondly, she is aware there have been problems since birth, so potentially this could have an impact on bonding. Thirdly, Shyamani knows that tube feeding is likely to be an option alongside oral feeding for a time, and it is probable that Suleiman may need surgery, so intervention to reduce oral aversions is also going to be of vital importance 2. Parent stress Shyamani knows the parents will be stressed, especially as this is their first child. She reflects on what this means in terms of management: this could include being prepared for frequent and repetitious questions, repeated modelling of strategies and an increased need to offer reassurance. There are also likely to be questions about the long-term implications of nasogastric tube feeding, so discussion around reducing oral aversion is going to have to be planned. 3. Appropriate support Using information from the research, Shyamani has reflected on using a mixture of approaches involving commenting positively on the parents strategies for feeding and managing oral aversion, as well as using some specific modelling and demonstration. Shyamani also realises that parents want information they can access themselves and that they can discuss with the clinicians they meet during Suleimans hospital stay. Being able to apply research to practice within the multidisciplinary team ensures that Shyamani is an active and competent team member.

IN PRACTICE What information can we gain from the research to inform our practice? 1. Ensure dysphagia work is embedded within a multidisciplinary team, and that all intervention is done in collaboration with the team and carers. In addition, appreciate that assessment may be a lengthy and time consuming process, but that the benefits will be vital in determining the most appropriate course of action. 2. Be proactive and - where possible preventative, by understanding the main types of difficulties within clinical groups. This helps to minimise risk by ensuring necessary additional help such as tube feeding is delivered in a timely way. It also allows therapists to consider what the potential difficulties could be, and therefore recognise when to ask for a second opinion or refer on to another professional or tertiary level team. 3. Appreciate that caring for infants and children who have feeding / physical / learning difficulties will affect all aspects of a familys life, including their sense of normality, social networks, general quality of life and overall wellbeing. This will impact on how therapists and families engage with each other and on parents ability to take on board advice. 4. Provide information in a timely way so parents can engage fully with services. This might involve enabling parents to get in

touch by email or text with any questions, or making proactive telephone calls between appointments. 5. In terms of service delivery, consider how to build on parental knowledge and skills, and include opportunities to demonstrate strategies rather than just advising. Ensure goals are functional and have a meaningful rationale (for example, include an oral care programme during tooth-brushing time, rather than having a separate time for an oral stimulation programme). This may lead to an improved level of developing and evaluating goals in collaboration with parents and carers, which in turn will contribute to an improved quality of life and better outcomes. An example of how Shyamani used the method is in figure 1. She says, Although I had had experience with dysphagia in community settings, I found myself in a position where I had to think quickly and actually devise a programme of intervention from a very early stage. On top of this, I knew the parents were stressed, but I felt I was trying to manage the immediate issues with the stress and the feeding problem rather than being structured in my approach to problem solving...During supervision, I was helped to think about having a structure for managing my intervention. I have found this method invaluable in enabling me to think about intervention, as well as giving me confidence SLTP when working with parents.

Celia Harding (email is a senior lecturer at City University and a speech and language therapist at the Royal Free Hospital. Dr. Christina Smith is at University College, Kirsty Harrison and Dr Naomi Cocks at City University and Chetan Vyas at The Wellington Hospital, all in London.

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how i

Bhatia, J. & Parish, A. (2009) GERD or not GERD: the fussy infant, Journal of Perinatology 29, pp.S7-S11. Davis, E., Shelly, A., Waters, E., Boyd, R., Cook, K. & Davern, M. (2009) The impact of caring for a child with cerebral palsy : quality of life for mothers and fathers, Child: Care, Health and Development 36(1), pp.63-73. Di Scipio, W.J. & Kaslon, K. (1982) Conditioned dysphagia in cleft palate children after pharyngeal flap surgery, Psychosom. Med. 44(3), pp.247-257. Douglas, J. (2002) Psychological Treatment of Food Refusal in Young Children, Child and Adolescent Mental Health 7(4), pp.173-180. DRC (2006) Equal Treatment: Closing the Gap. A formal investigation into physical health inequalities experienced by people with learning disabilities and / or mental health problems. London: Disability Rights Commission. Dyson, L.L. (2003) Children with learning disability within the family context: a comparison with siblings in global selfconcept, academic self-perception and social competence, Learning Disabilities: Research and Practice 18(1), pp.1-9. Feldman, M., Varghese, J., Ramsay, J. & Rajska, D. (2002) Relationships between Social Support, Stress and MotherChild
SLT in Practice:Layout 1 12/4/11

Interactions in Mothers with Intellectual Disabilities, Journal of Applied Research in Intellectual Disabilities 15(4), pp.314-323. Field, D., Garland, M. & Williams, K. (2003) Correlates of specific childhood feeding problems, Journal Paediatric Child Health 39, pp.299-304. Harding, C. & Wright, J. (2010) Dysphagia: The challenge of managing eating and drinking difficulties in children and adults who have learning disabilities, Tizard Learning Disability Review 15(1). Hendrix, T.R. (1993) Art and science of history taking in the patient with difficulty swallowing, Dysphagia 8(2), pp.69-73. Hewetson, R. & Singh, S. (2009) The lived experience of mothers of children with chronic feeding and/or swallowing difficulties, Dysphagia 24(3), pp.322-332. Hoddinott, P. & Pill, R. (2000) A qualitative study of womens views about how health professionals communicate about infant feeding, Health Expectations 3, pp.224-233. Hofner, G., Behrens, R., Koch, A., Singer, H. & Hofbeck, M. (2000) Enteral nutritional support by percutaneous endoscopic gastrostomy in children with congenital heart disease, Paed. Cardiology 21(4) 341-6. Mathisen, B., Worrall, L., Masel, J., Wall, C. & Shepherd, R.W. (2002) Feeding problems in infants with gastro-oesophageal reflux
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disease: a controlled study, J Paediatr Child Health 35(2), pp.163-169. Quartino, A.R. (2006) Down syndrome specificity in health issues, in Rondal, J. & Perera, J. (eds.) Down syndrome: Neurobehavioural Specificity. Sussex, UK: John Wiley & Sons, pp.53-66. Reilly, S., Skuse, D. & Poblete, X. (1996) Prevalence of feeding problems and oral motor dysfunction in children with cerebral palsy: A community survey, Journal of Pediatrics 129(6), pp.877-882. Sleigh, G. (2005) Mothers voice: a qualitative study on feeding children with cerebral palsy, Child: Care, Health and Development 31(4), pp.373-383. Sloper, P., Knussen, C., Turner, S. & Cunningham, C. (1991) Factors related to stress and satisfaction with life in families of children with Downs syndrome, Journal of Child Psychology and Psychiatry 32(4), pp.655-676. Sloper, P. & Turner, S. (1993) Risk and resistance factors in the adaptation of parents of children with severe physical disability, Journal of Child Psychology and Psychiatry 34(2), pp.167-188. Sullivan , P.B., Lambert, B., Rose, M., Ford-Adams, M., Johnson, A. & Griffiths, P. (2000) Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford Feeding Study, Dev Med Child Neurol 42(10), pp.674-680.


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How I use the evidence in dysphagia management (2):

A question of taste
Hannah Crawford and Julie Bake explain why and how, in a move away from previous practice, they now implement oral taster programmes with people with learning disabilities and dysphagia who gain their nutrition via percutaneous endoscopic gastrostomy (PEG).


s practitioners working with people with profound and multiple disabilities, including learning disabilities, we have found that family and carers are often reluctant to go ahead with PEG (Percutaneous Endoscopic Gastrostomy) placement to support nutritional and/or dysphagic needs. While it is usually difficult to discuss the issues with the client due to limited capacity, they are often able to indicate whether eating and drinking is pleasurable. Carers and family frequently feel that, when the person does enjoy this, their quality of life would suffer if they were no longer able to eat or drink. In the past we felt that the risk of implementing any level of oral intake with someone who was dysphagic and suffered recurrent chest infections was too high to justify. However, reflecting on our role as health professionals, we are increasingly aware of the tension between our ethical responsibilities: to do no harm, to do the most good, to implement equitable practice - but to allow patients or clients to be autonomous, and support them in decision making about their own health. Sometimes the answers are not clear cut. Clients dont present like text book cases, and the answers or the most appropriate treatment routes are not always the most obvious, nor necessarily the ones we would choose for ourselves. In recent years, the publication of key papers led us to reconsider our approach: A seminal paper by Langmore et al. (1998) clearly identifies the factors relevant in the development of aspiration pneumonia. Mackie (2001) summarises the pros and cons of the use of PEG, and argues for the consideration of not only the technical aspects but also ethical, quality of life and moral issues to do with food and feeding. The Mental Capacity Act (2005) urges us to act in the least restrictive manner, and to allow patients to be autonomous and make unwise decisions. Reviewing the evidence in 2005, Macleman suggested this course of action, stating that my opinion has shifted towards always

Photo of Richard with Julie Bake by

considering and assessing for oral tasters post-PEG (p.22). We now work towards implementing some level of oral intake for all our clients receiving PEG feeds who have shown they want to have this. We use Sackett et al.s framework of evidence based practice (1996), with its three overlapping

circles representing client preference, clinical experience and best available evidence, to give context to our decision making. We consider each client in relation to Langmore et al.s (1998) predictors of aspiration pneumonia (figure 1). We look at the risk factors we are concerned about,




Figure 1 Predictors of aspiration pneumonia (Langmore et al., 1998) Dependent for oral care? Several decayed teeth? Multiple medications? Tube fed? Figure 2 Discussion framework (based around Sackett et al., 1996)


Client preference Discuss: clients wishes observations and thoughts of familiar care staff preferences of family


Large volume aspiration? Oral intake? Reflux? Micro aspiration? Saliva? Reflux?


Smoker now? Or in past? Lung disease? Multiple medical diagnoses?

Discuss experience with similar cases managed Review case history, assessment fndings and resulting recommendations

Discuss evidence: quality of life factors affecting severity of chest infections control the indicators for the development of aspiration pneumonia


Risk of developing chest infections or pneumonia?

Clinical experience

Best available evidence

and use this to guide the amount, type and frequency of oral intake or tasters as well as the associated recommendations. Working through this flow diagram, we advise ensuring teeth are clean, either getting the client to engage in good tooth brushing, or encouraging family or carers to do this regularly. Where required we also engage dental services to support this. If there are significant concerns about chest status we attempt to reduce the amount of aspiration by limiting tasters to the most that we feel the client can cope with, down to only a spoon handle dip rather than teaspoons. We engage GPs and dietitians to ensure any reflux is addressed and stabilised where possible. We take into account general health and diagnoses, and whether these are stable, before implementing any oral intake or tasters programme. We also look at the overall pattern of chest status in dictating the amount and regularity of tasters. We still recommend oral intake or tasters if clients suffer from chest infections, but we are more cautious as to amounts. We also ensure that all decisions about the implementation of tasters take place at a multidisciplinary planning meeting, including a Mental Capacity Act (2005) Best Interests discussion. We state that we cant rule out a client continuing to have some chest problems but, if we control the indicators for the development of aspiration pneumonia, then the chest infections are likely to have developed whether the client was having tasters or not. We then have to debate as a multidisciplinary team whether this risk is ethically acceptable. These decisions need to be made on an individual client basis by the

team, with family and carers involved, as well as the client where possible (see discussion framework in figure 2).


We have now worked with sufficient clients on various levels of tasters to know that their carers report benefits including: a) Ongoing use of skills: Tasters allow her to continue to use her sense of taste. b) Increased quality of life: She enjoys experiencing different things and is able to express her favourites. c) Social benefits: He looks forward to having his tasters; he enjoys them and it includes him in the social aspect of eating and drinking. Some of the negative aspects have included a client wanting more than is indicated on the recommendations, or when a client eats well it can affect their PEG regime. A key indicator for action is any distress experienced by the client. If the client coughs or shows signs of distress on oral intake, we consider limiting or not going ahead with tasters. Where a client is non-verbal, or where there is debate about signs of distress, tools such as the DisDAT (Regnard et al., 2007) are extremely useful in mapping regularity, pattern and intensity. We have for example used this tool to help look at optimal timing of oral intake. For one client we mapped distress levels throughout the day. This indicated that they peaked at times of oral intake, so we were able to work with carers and family to reduce intake to a smaller level of tasters. For another client, staff reported distress at taster times and wanted

to reduce them. However, with DisDAT, we were able to show distress was in no way associated with tasters but was consistent across days and linked to other causes. Our oral intake or tasters programmes ultimately aim to address the clients choice - what the client would want. It may be that the client, carers and team agree to accept a small level of risk in continuing to implement the programme. This needs to be addressed with good multidisciplinary planning and risk management, incorporating clinical factors as discussed earlier such as good oral hygiene and stopping in periods of ill health. Julie will now outline her work with Richard to illustrate the implementation of a tasters programme:

ichard is a 62 year old gentleman living in a group home. He has spastic cerebral palsy, particularly affecting the function of his left side. He has moderate learning disabilities and is non verbal, however is very able to get his message across using gesture, facial expression and vocal intonation. Richard was referred to our speech and language therapy service following deterioration in his eating and drinking skills and recurrent chest infections. Following a full eating and drinking assessment, Hannah completed a videofluoroscopy which identified significant oral and pharyngeal difficulties. Of particular concern were a rigid epiglottis - which resulted in a complete inability to protect his airway while swallowing - and dysmotility of the oesophagus. Both Hannah and his care providers had concerns that these problems would continue to have a considerable impact on Richards enjoyment




of eating, hydration levels, chest condition and on his general health and wellbeing. Following discussion with Richard and the multidisciplinary team, he had a PEG inserted. A subsequent change in manager in the home meant that for a year we didnt have contact with Richard, and didnt formally implement a tasters programme. About a year later we were having discussions with the new manager of Richards home. It became apparent that she had offered him some tasters, which Richard had really enjoyed, and we agreed to start a formal tasters programme. However, there was tension among the staff group at the home, with some reluctance to implement a programme because of concern about Richards health, having seen the videofluoroscopy. They were concerned that Richard would choke, that he would become unwell again, or that very small amounts of food would be tormenting rather than pleasurable. We discussed all their concerns, and the evidence to support the implementation of tasters which would aim to address Richards quality of life and risk. Hannah recommended a programme tailored to deal with some of the issues raised by Richards care staff at home. The manager of Richards day service rather than the home - volunteered to roll out a tasters programme with the full support of speech and language therapy (figure 3). My role as a nutritional practitioner has been central to this case. The role has developed over time and is particularly valuable to the team. I am a senior Allied Health Professions assistant, shared and co-supervised between speech and language therapy and dietetics. I work only with people with eating and drinking difficulties. In support of dietetics management, this includes people who need nutritional support or weight management. In support of speech and language therapy, I monitor people who are stable, or check dysphagia recommendations are being followed. In some cases, as with Richard, a client is receiving involvement from both professions. Hannah asked me to see Richard to roll out taster sessions with permanent key staff at the day centre. I made several visits and worked with each member of staff individually, demonstrating how to support Richard to have tasters. His enjoyment of these tasters - and the pleasure of staff at seeing this enjoyment - was very apparent. The sessions have now developed and are a focal point of his day. In the morning Richard also goes shopping to choose what taster hell have that day. I am currently going into Richards home to demonstrate taster sessions there, and Richard continues a year later in good health SLTP and enthusiastic about his oral intake. Hannah Crawford (email hannah.crawford@ is a consultant speech and language therapist and Julie Bake (email julie. is a nutritional practitioner with Tees, Esk & Wear Valleys NHS Foundation Trust in Middlesbrough.
Figure 3 Richards taster programme Tees, Esk and Wear Valleys NHS Foundation Trust Name: Richard Current feeding status: PEG Date of birth: NHS no.: Carers aware of programme: Richard indicated keen to try food, all carers aware

Is there a recent dysphagia assessment? Yes Times when tastes should be introduced: During lunch time at day service Times when tastes should be avoided: Half an hour before PEG feeds or up to an hour after PEG feeds Avoid if Richard tired, unwell or has a chest infection Drink / Food types to be offered / preferred: Mousse, trifle, yoghurt, dream topping, ice cream, pureed fruit Positioning: Richard should be upright and midline, in a stable supportive position Method of delivery and quantity offered: Dip handle of plastic spoon in food and pull out so handle is coated only Give spoon to Richard so he can feed himself 3 dips only then stop Consistency of taste: Completely smooth and totally lump free consistency Indicators of enjoyment: Asking for more Smiling Indicators to stop: Coughing Unhappy facial expressions and refusal Required experience of the person assisting / named people: Permanent, experienced members of staff Method of recording session: Recording sheets Person compiling programme and review date: Hannah Crawford (Consultant Speech & Language Therapist) Other instructions: Give verbal and visual prompts that 3 tasters only, and count Richard down Give plenty reassurance that there will be more tomorrow Maintain scrupulous oral hygiene programme Form designed by Katie Ferguson, Speech & Language Therapist, TEWV NHS FT

Langmore, S.E., Terpenning, M.S., Schork, A., Chen, Y., Murray, J.T., Lopatin, D. & Loesche, W.J. (1998) Predictors of aspiration pneumonia: how important is dysphagia?, Dysphagia 13(2), pp.69-81. Mackie, S.B. (2001) PEGs and Ethics, Gastroenterology Nursing 24(3), pp.138-142. Macleman, Y. (2005) To taste or not to taste, Speech & Language Therapy in Practice Summer, pp.20-22. Mental Capacity Act (2005) Available at: contents (Accessed: 20 April 2011). Regnard, C., Reynolds, J., Watson, B., Matthews, D., Gibson, L. & Clarke, C. (2007) Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT), J Intellect Disability Res 51(4), pp.277-292. Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., Haynes, R.B., & Richardson, W.S. (1996) Evidence-based medicine: What it is and what it isnt, British Medical Journal 312, pp.71-72.


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1. SOCIAL NETWORKS A clients partner, family and friends are vital and need our support in order to understand their loved ones difficulties, make the most of communication, and enable safe eating and drinking. The importance of supporting carers, particularly in the early stages, is highlighted in the National Dementia Strategy (2009). Chatter Matters by Colin Barnes is a great resource for helping to talk through communication issues, and Care to Communicate: Helping the Older Person with Dementia by Jennie Powell is useful for carers (or therapists) who want to read about more ideas. Barnes, C.J. (2003) Chatter Matters: advice on communication for carers, Journal of Dementia Care 11(5), pp.19-21. Department of Health (2009) Living well with dementia: A National Dementia Strategy. Available at: Publicationsandstatistics/Publications/ PublicationsPolic yAndGuidance/ DH_094058 (Accessed 21 March 2011). Powell, J. (2000) Care to Communicate: Helping the Older Person with Dementia. London: Hawker Publications. 2. PRESENCE IN CARE HOMES Training and support for carers in care homes is vital to ensure safe eating and drinking and good communication, but there are a number of imaginative ways this can be achieved in addition to traditional classroom-style lectures. Some of us have special arrangements with individual care homes who allow us to be involved in handover or inservice programmes, while others have innovative ways to get people to attend the training (such as just turning up and starting a workshop in the lounge!) Getting this right can do wonders for our reputation, and we need to develop a presence and profile in order to be taken seriously. This doesnt however mean we have to do everything ourselves, and the nutrition companies can be very helpful. For example the dysphagia representatives at Fresenius are able to offer training to care homes, and Nutilis produces tear-off pads showing how many scoops of thickener are needed for each drink. Fresenius, Nutilis, 3. COMMUNICATION BOOKS / MEMORY BOARD Communication books are not just books meant for communicating messages but chat books, scrap books, life books, memory

albums, eating / drinking guidelines, likes / dislikes, communication strategy sheets and even DVDs. These arent just for use in the home but are invaluable for taking to day centres, or if a client is admitted to hospital or moved to a care home, particularly in an emergency. A memory board is less involved and time consuming than a communication book, and could be as simple as a list of key people and issues for the client. 4. CONVERSATION STARTERS Another great idea is using communication cards with conversation starters to help get things going, such as Did you watch something on the telly this afternoon? or What did you do when Jane visited? You can buy and sort commercially available cards, but making your own will suit individual clients. 5. PERSONAL OBJECTS Clients often have personal objects that mean or represent something to them. We can use these - and pictures and symbols - to enable better understanding of a client as a person and to facilitate better communication with them. This is particularly useful for care home residents. Some care homes allow us to personalise doors with objects and pictures to represent the person whose room it is, for example a toy aeroplane on the door of a retired air-hostess with many a tale to tell. 6. TV GUIDES Simple pictorial or symbol based TV guides help clients participate in choosing what to watch. This can also facilitate the choice of better TV programmes for clients to enjoy with their partners. They might for example find it easier to engage with more straightforward programmes with less dialogue, such as a wildlife feature rather than a complex murder mystery. I use a grid for each day, with pictures of the major channel logos down the side, and 10 pictures across the top to represent the time of day from early morning to bedtime. I then add in pictures of programmes, which you can get readily from Google Images. You could also laminate a basic grid, then Velcro on pictures depending on the day, removing only the ones the client doesnt want to watch. 7. FREECYCLE Freecycle is an online forum where people give away unwanted goods. It can be a

marvellous resource for getting hold of useful items, particularly reminiscence materials. You sign up to your regional group (for free) and then post a message saying what you want, for example, wanted old adverts, ration books, vinyl records, etc. Then you just wait to see if a group member has what youre looking for. Freecycle, 8. TALKING MATS Talking Mats is an evidence-based low tech communication framework using a mat with picture symbols attached. There is a specific dementia pack, and the tool can be great for identifying a clients preferences in all sorts of situations. When we get stuck for a suitable picture we use Google Images. Further information about Talking Mats & Dementia, including links to research papers on effectiveness and decision making, is at Package-Dementia.htm. 9. INTERVENTION Most of us believe that there is a place for 1:1 therapy intervention in dementia. Between us weve tried things from other fields like errorless learning (often used in aphasia but gaining ground in the dementia literature), and Intensive Interaction, an approach to teaching pre-speech communication to children and adults with learning disabilities. Kessels, R.P. & Hensken, L.M. (2009) Effects of errorless skill learning in people with mildmoderate or severe dementia: a randomized controlled pilot study, NeuroRehabilitation 25(4), pp.307-312. For more on Intensive Interaction, see 10. THE WIDER TEAM The multidisciplinary team and voluntary sector can be invaluable for joint training or joint input. Some of us have been involved in Occupational Therapy groups, and many of us have used the Alzheimers Society for their wealth of information and local support in various guises. This can include individual and group peer support for clients and families in the early, mid and late stages of dementia, Ageing Cafes, and resources and information giving for professionals. Alzheimers Society,